Patients' and health professionals' views on primary care for people with serious mental illness : focus group study

Objective To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting Six primary care trusts in the West Midlands. Participants Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and prefer-red to consult their own GP, who listened and was willing to learn, rather than be referred to a different,GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms ("acted up") to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness

Integrated mental health services in England: a policy paradox

PURPOSE: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. DATA SOURCES: Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. CONCLUSION: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. DISCUSSION: We conclude with suggestions for strategies that may facilitate more integrated working

An exploration of the value and mechanisms of befriending for older adults in England

Social isolation and loneliness in older adults are growing problems. Empirical research suggests that loneliness can lead to poorer health outcomes including higher mortality rates. Befriending has been shown to decrease loneliness and depression although the exact mechanisms of action are unclear. In this study we aimed to explore experiences and identify key ‘ingredients’ of befriending through interviews conducted with 25 older adults who had used five different befriending services across England. We used Berkman's theoretical model of how individual social networks impact on health to help interpret our data and explore the mechanisms of befriending for older adults. Findings suggest that befriending offers some compensation for loss of elective relationships from older adults’ social networks, providing opportunities for emotional support and reciprocal social exchange through development of safe, confiding relationships. Good conversational skills and empathy were the foundation of successful relationships within which commonalities were then sought. Befrienders broadened befriendees’ perspectives on life (particularly among older adults in residential care). Social engagement was a powerful mechanism of action, particularly in terms of connecting people back into the community, reinforcing meaningful social roles and connecting to a past life that had often been significantly disrupted by loss. Understanding key components and mechanisms of befriending for older adults may facilitate development of more effective and theoretically sound befriending services

Human Rights and Humanitarian Law in Collision: A Study of the Case of Omar Khadr, a Child Soldier Detained at Guantanamo

Omar Khadr, age 15 and a citizen of Canada, was given emergency medical care for near-fatal gun-shot wounds and taken into custody by U.S. forces in Afghanistan on July 27, 2002. U.S. military forces had been in that country since October of 2001, only a month after the devastating attacks on the United States of September 11. Omar Khadr was, without doubt, a child on the date of his detention and all prior dates of his alleged criminal conduct. He was, however, caught up on that July day in a prolonged military encounter with deaths on both sides including, very nearly, his own. Some would thus first characterize him not as a child but as a combatant – “child soldier” is the term most often applied in such situations, but the more neutral “child in armed conflict” is generally used here

Don’t turn your back on the symptoms of psychosis : a proof-of-principle, quasi-experimental public health trial to reduce the duration of untreated psychosis in Birmingham, UK

Background: Reducing the duration of untreated psychosis (DUP) is an aspiration of international guidelines for first episode psychosis; however, public health initiatives have met with mixed results. Systematic reviews suggest that greater focus on the sources of delay within care pathways, (which will vary between healthcare settings) is needed to achieve sustainable reductions in DUP (BJP 198: 256-263; 2011). Methods/Design: A quasi-experimental trial, comparing a targeted intervention area with a ‘detection as usual’ area in the same city. A proof-of–principle trial, no a priori assumptions are made regarding effect size; key outcome will be an estimate of the potential effect size for a definitive trial. DUP and number of new cases will be collected over an 18-month period in target and control areas and compared; historical data on DUP collected in both areas over the previous three years, will serve as a benchmark. The intervention will focus on reducing two significant DUP component delays within the overall care pathway: delays within the mental health service and help-seeking delay. Discussion: This pragmatic trial will be the first to target known delays within the care pathway for those with a first episode of psychosis. If successful, this will provide a generalizable methodology that can be implemented in a variety of healthcare contexts with differing sources of delay. Trial registration: http://www.controlled-trials.com/ISRCTN45058713 Keywords: Public mental health campaign, First-episode psychosis, Early detection, Duration of untreated psychosis, Youth mental healt

Designing and evaluating complex interventions to improve health care

Complex interventions are “built up from a number of components, which may act both independently and interdependently.”1 2 Many health service activities should be considered as complex. Evaluating complex interventions can pose a considerable challenge and requires a substantial investment of time. Unless the trials illuminate processes and mechanisms they often fail to provide useful information. If the result is negative, we are left wondering whether the intervention is inherently ineffective (either because the intervention was inadequately developed or because all similar interventions are ineffective), whether it was inadequately applied or applied in an inappropriate context, or whether the trial used an inappropriate design, comparison groups or outcomes. If there is a positive effect, it can be hard to judge how the results of the trial might be applied to a different context (box 1)

Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

Objectives To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework

Portugal's Nonprofit Sector in Comparative Context

This is a report comparing the scope, composition, and revenue of the nonprofit sector in Portugal to its counterparts in other countries. The report draws on the important new source of data on nonprofit institutions (NPIs) that has resulted from the implementation of the United Nations Handbook on Nonprofit Institutions in the System of National Accounts, including particularly the recently issued results generated by Portugal's Instituto Nacional de Estatistica - INE (National Institute for Statistics) in its Nonprofit Institutions Satellite Account