Costing practice nurses: implications for primary health care

General medical practice has changed significantly in the past ten years, reflecting a range of innovations giving greater priority to health prevention and promotion and to primary health care generally. One consequence has been a rapid increase in the number of practice nurses. Since 1988 the number of whole-time equivalents has trebled and most practices now employ at least one nurse. Practice nurses make an increasingly important contribution to both the practice team and the delivery of primary health care. They undertake a wide range of activities, in the practice and the patient’s home, including traditional nursing tasks, chronic disease management, health promotion, new patient registration health checks, counselling, advice, investigation, treatment and health assessments of elderly people. There is, however, widespread uncertainty about their role and how it might develop. Cost has been largely ignored because where the money comes from, that is who bears the cost of practice nurses, is to a great extent divorced from the responsibility for their employment. General medical practitioners who employ nurses are usually reimbursed by Family Health Service Authorities for most of the nurse’s salary. This paper provides unit cost estimates of practice nurses and discusses the implications for their future role and deployment. As well as direct costs, it considers the wider opportunity cost associated with the growth in practice nurse numbers.nurse, primary care, general practice

Can general practitioner commissioning deliver equity and excellence? : Evidence from two studies of service improvement in the English NHS

Objectives: To explore some of the key assumptions underpinning the continued development of general practitioner-led commissioning in health services. Methods: Qualitative data from two studies of service improvement in the English NHS were considered against England's plans for GP-led commissioning. These data were collected through in-depth interviews with a total of 187 professionals and 99 people affected by services in 10 different primary care trust areas across England between 2008 and 2009. Results: Internationally, GPs are seen to have a central position in health systems. In keeping with this, the English policy places emphasis on the 'pivotal role' of general practitioners, considered to be ideally placed to commission in the best interests of their patients. However, our evidence suggests that general practitioners do not always have a pivotal role for all patients. Moreover, it is planned that the new commissioning groups in England will not be subject to top-down performance management and this raises the question of how agreed quality standards will be met under the proposed new system. Conclusions: This paper questions the assumption that GPs are best placed to commission health services in a way that meets quality standards and leads to equitable outcomes. There is little evidence to suggest that GPs will succeed where others have failed and a risk that, without top-down performance management, service improvement will be patchy, leading to greater, not reduced, inequity

‘Talk to Me. There’s Two of Us’ : Fathers and Sickle Cell Screening

Studying kinship has involved doing family, displaying family and ‘displaying family’ as a sensitising concept to understand modalities troublesome to display. Fathers at antenatal screening clinics for sickle cell are faced with pressures to produce multiple displays – of family, illness knowledge, the good father and the model citizen – often in the face of racialised identities. Such fathers emphasise the importance of hypervisibility in gendered spaces and hypervigilence, lest pressures to adopt the ‘right’ disposition have adverse consequences for themselves, partners or their children. The displays of fathers, as well as displays they decline, are orientated to repair of social relationships. Where displays are provoked by social relations – resisting racist or gender stereotypes, navigating citizenship uncertainties, negotiating work and family lives – displays become problematic. Family display becomes troubled where the preferred social relationships fathers seek to constitute are ones that are not readily accommodated within extant social relations

Experiences of living with chronic myeloid leukaemia and adhering to tyrosine kinase inhibitors: A thematic synthesis of qualitative studies

Purpose: To investigate the experiences of adults living with chronic myeloid leukaemia and treated with tyrosine kinase inhibitors, with particular reference to factors influencing adherence. Methods: A thematic synthesis of all published qualitative studies examining adults with chronic myeloid leukaemia, receiving tyrosine kinase inhibitors. Eligible publications were identified by searching five electronic databases using defined criteria. The synthesis involved complete coding of extracted data and inductive theme development. Results: Nine studies were included and three overarching themes defined. Overarching themes were: 1) Disease impacts whole life; 2) Disease management strategies; and 3) Valued aspects of care. Side-effects often required physical and psychological adaptation. Patients developed individual decision-making processes to promote adherence and manage side effects. Unintentional non-adherence occurred due to forgetfulness and system failures. Intentional omission also occurred, which together with side effects, was unlikely to be reported to healthcare professionals (HCPs). HCP reassurance about missed doses could reinforce non-adherence. Information needs varied over time and between individuals. Knowledge among patients about treatment was often lacking and could lead to misunderstandings. Patients valued psychological support from HCPs and suggested an individualised approach, facilitating discussion of symptoms, adherence and their perspectives about living with chronic myeloid leukaemia, would improve care. Conclusions: Patients with chronic myeloid leukaemia experienced significant side-effects from treatment and changes to their psychological and physical well-being. They developed their own strategies to manage their disease and treatment. This should be recognised in interventions to improve education, support and the delivery of care that is compassionate and adequately resourced

Living with inflammatory bowel disease : the experiences of adults of South Asian origin

Globally IBD is most prevalent in Europe and North America, and in recent years there has been an increase in incidence in people of South Asian origin living in these countries. However, little is known about their experience of the condition. This is of concern because it has been known for some time that minority ethnic groups with a range of health conditions encounter barriers to accessing acceptable health and other support services. The aim of the LISA Project was to describe what living with IBD is like for South Asian adults, and to understand whether ethnicity impacts on this experience and, if so, how

Enhancing Gypsy, Roma and Traveller peoples’ trust:using maternity and early years’ health services and dental health services as exemplars of mainstream service provision

Gypsies, Roma and Travellers (GRT) are socially excluded groups where evidence for improving health is weakest. Although GRT communities are diverse, and robust evidence of health needs is lacking, there is consensus that GRT in the UK have poorer health and lower life expectancy than the general population and other disadvantaged groups. Reasons why GRT are vulnerable to poor health outcomes include poor living conditions, high rates of homelessness, low educational achievement, social exclusion, widespread prejudice and discrimination and barriers to accessing healthcare. These multiple factors, alongside poor quality care that does not meet needs, may lead to low expectations and mistrust of health services. Trust in services and personnel is associated with increased utilisation of healthcare, improved health behaviours and quality of care. Community engagement strategies have the potential to enhance trust and ensure services are tailored to the needs of specific populations. This multi-component study aimed to strengthen evidence on how to improve uptake and delivery of health services and thereby reduce health inequalities for GRT

Chronic Myeloid Leukaemia : A Qualitative Study of Patient and Practitioner Experiences of Managing Treatment

Background. Following the dramatic impact of tyrosine kinase inhibitor (TKI) drugs on chronic myeloid leukaemia (CML) survival, research interest has grown into the long-term impact of treatment, identifying difficulties with medication adherence and ongoing side effects. Qualitative studies suggest the disease has a significant physical and psychological impact on patients, and medication management may be complex. However, only one study worldwide has examined healthcare practitioner (HCP) experiences of managing CML treatment and very little UK qualitative research exists exploring the patient experience. Purpose. Our qualitative study aimed to investigate both patient and HCP experiences of managing CML treatment in the UK. Methods. Patients and HCPs were purposively sampled from within the Haematological Malignancy Research Network (HMRN), a UK population-based patient cohort. Qualitative interviews were carried out with seventeen patients and thirteen HCPs, and data were analysed using thematic analysis. Results. Four themes were developed from interview analysis: “Importance of optimal clinical management,” “Multiple adherence strategies,” “Inconsistent management of adherence,” and “Controlling side effects is complex.” HCPs tended to focus on sometimes complex, clinical decision-making. Patients described various strategies to support adherence and manage side effects, some of which HCPs seemed to be less aware of. Several patients did not discuss non-adherence or side effects with their HCP, who tended to avoid direct enquiry regarding adherence and could be uncertain about adherence advice, whilst relying on medical strategies to manage side effects. Conclusions. Despite HCPs focusing on the medical management of CML treatment, patients may opt to use self-management techniques to control adherence and side effects and can be reluctant to discuss related difficulties. Increased clinic time and clear adherence advice guidance may support such discussion, in addition to adjusting the context of follow-up care through the introduction of shared care with GP services