Implementing change in primary care practice: lessons from a mixed-methods evaluation of a frailty initiative

© 2018, BJGP Open. Background: The NHS is facing increasing needs from an aging population, which is acutely visible in the emerging problem of frailty. There is growing evidence describing new models of care for people living with frailty, but a lack of evidence on successful implementation of these complex interventions at the practice level. Aim: This study aimed to determine what factors enable or prevent implementation of a wholesystem, complex intervention for managing frailty (the PACT initiative) in the UK primary care setting. Design & setting: A mixed-methods evaluation study undertaken within a large clinical commissioning group (CCG). Design and analysis was informed by normalisation process theory (NPT). Method: Data collection from six sites included: observation of delivery, interviews with staff, and an online survey. NPT-informed analysis sought to identify enablers and barriers to implementation of change. Results: Seven themes were identified. PACT was valued by professionals and patients but a lack of clarity on its aims was identified as a barrier to implementation. Successful implementation relied on champions pushing the work forward, and dealing with unanticipated resistance. Contracts focused on delivery of service outcomes, but these were sometimes at odds with professional priorities. Implementation followed evidence-informed rather than evidence-based practice, requiring redesign of the intervention and potentially created a new body of knowledge on managing frailty. Conclusion: Successful implementation of complex interventions in primary care need inbuilt capacity for flexibility and adaptability, requiring expertise as well as evidence. Professionals need to be supported to translate innovative practice into practice-based evidence

Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation

Background: Australians living in rural and remote areas have access to considerably fewer doctors compared with populations in major cities. Despite plentiful, descriptive data about what attracts and retains doctors to rural practice, more evidence is needed which informs actions to address these issues, particularly in remote areas. This study aimed to explore the factors influencing General Practitioners (GPs), primary care doctors, and those training to become GPs (registrars) to work and train in remote underserved towns to inform the building of primary care training capacity in areas needing more primary care services (and GP training opportunities) to support their population’s health needs. Methods: A qualitative approach was adopted involving a series of 39 semi-structured interviews of a purposeful sample of 14 registrars, 12 supervisors, and 13 practice managers. Fifteen Australian Medical Graduates (AMG) and eleven International Medical Graduates (IMG), who did their basic medical training in another country, were among the interviewees. Data underwent thematic analysis. Results: Four main themes were identified including 1) supervised learning in underserved communities, 2) impact of working in small, remote contexts, 3) work-life balance, and 4) fostering sustainable remote practice. Overall, the findings suggested that remote GP training provides extensive and safe registrar learning opportunities and supervision is generally of high quality. Supervisors also expressed a desire for more upskilling and professional development to support their retention in the community as they reach mid-career. Registrars enjoyed the challenge of remote medical practice with opportunities to work at the top of their scope of practice with excellent clinical role models, and in a setting where they can make a difference. Remote underserved communities contribute to attracting and retaining their GP workforce by integrating registrars and supervisors into the local community and ensuring sustainable work-life practice models for their doctors. Conclusions: This study provides important new evidence to support development of high-quality GP training and supervision in remote contexts where there is a need for more GPs to provide primary care services for the population

Insight into rural and remote GP training and supervision in Queensland

Many rural and remote communities are struggling to attract and retain GPs while experiencing poorer population health outcomes and burden of disease. Therefore, the provision of a reliable rural GP workforce is vital. Registered Training Organisations provide high quality training experiences for GP registrars. A collaborative project between JCU and Monash University aimed to identify aspects of GP training which impact registrars’ experience. Perspectives were obtained from GP registrars, supervisors, and practice managers. This presentation focuses on training and supervision aspects in rural and remote north-west Queensland. A mixed methods study was undertaken and both quantitative and qualitative data were collected. A modified survey based on the adapted Critical Access Hospital Community Apgar Questionnaire was used to collect data about perceptions of rural GP training and supervision with the highest rated factor being medical quality and the lowest rated being scope of practice. Semi-structured interviews were then used to gather additional information about training and supervision experiences. Interviews were thematically analysed and primary themes relating to attractors and barriers for workforce training and supervision, and impact of rural remote practice were elicited. Attractors included lifestyle, rural medicine, scope of practice, services and incentives while barriers included workforce factors, lifestyle, location, services and incentives. Rural remote GP training experiences contribute a variety of attractors and barriers which impact on a positive training experience for registrars. Identification of these factors make it possible to tailor training accordingly and foster a positive rural experience that may translate to a future reliable workforce

Key elements of effective postgraduate GP educational environments: a mixed methods study

Objectives Evidence in the literature suggests that satisfaction with postgraduate general practice (GP) training is associated with the quality of the educational environment. This study aimed to examine GP registrars’ level of satisfaction with a distributed model of training in a regional educational environment and investigate the relationship between satisfaction and academic performance. Study design A longitudinal 3-year study was conducted among GP registrars at James Cook University using a sequential explanatory mixed methods research design. GP registrars’ satisfaction was obtained using the scan of postgraduate educational environment domains tool. A focus group discussion was conducted to explore GP registrars’ perceptions of satisfaction with the educational environment. Setting James Cook University General Practice Training (JCU GPT) programme. Participants Six hundred and fifty one (651) GP registrars enrolled between 2016 and 2018 at JCU GPT programme. Results 651 registrars completed the satisfaction survey between 2016 and 2018. Overall, 92% of the registrars were satisfied with the educational training environment. Registrars who had become fellows reported higher satisfaction levels compared with those who were still in training (mean=4.39 vs 4.20, p=0.001). However, academic performance had no impact on level of satisfaction with the educational environment. Similarly, practice location did not influence registrars’ satisfaction rates. Four themes (rich rural/remote educational environment, supportive learning environment, readiness to continue with rural practice and practice culture) emerged from the thematic data analysis. Conclusion A clinical learning environment that focuses on and supports individual learning needs is vital for effective postgraduate medical training. This study suggests that JCU GPT programme’s distributed model fostered a satisfying and supportive training environment with rich educational experiences that enhance retention of GP registrars in rural/remote North Queensland, Australia. The findings of this study may be applicable to other settings with similar training models

‘Is Gold Dust to My Mind’: Exploring Lived Experience in Social Work Education

The involvement of people with lived experience (service participants) is mandatory within UK social work education, although the form this takes varies significantly between organisations. This article outlines the final phase of a two-year research project focused on understanding the mechanisms which support and develop the meaningful and sustainable involvement of people with lived experience in social work education within a Higher Education Institution and a Local Authority Teaching Partnership in the East of England. The research team worked collaboratively using co-production principles and possessed lived experience backgrounds. This article presents findings from a qualitative study using interviews and questionnaires that aimed to deepen understanding of the concept and practice of embedding lived experience in social work education. Thematic analysis identified a dedicated role with the motivation and drive to achieve sustained inclusion in creative ways was the underpinning of meaningful and sustainable lived experience involvement. This was alongside opportunities to shape diverse and relational learning experiences, values reflecting compassionate and respectful relationships, and power sharing, accompanied by practical resources, can create a culture change. Together, these principles, practices and values have been instrumental in creating meaningful and sustainable lived experience involvement within social work education

The challenge of measuring intra-individual change in fatigue during cancer treatment

Evaluate how well three different patient-reported outcomes (PROs) measure individual change

Validation of the PROMIS physical function measures in a diverse US population-based cohort of cancer patients

To evaluate the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function measures in a diverse, population-based cancer sample

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms