General practitioners: allies or enemies of primary health care

In this paper the thesis is advanced that the general practitioners can either be a powerful ally or a major roadblock in the development of primary health care in the spirit of the Alma-Ata Declaration. The role they will play depends on their interpretation of, and attitudes towards, the concept. In the first part of the paper, four common interpretations of primary health care (primary health care as a set of activities; as a level of care; as a strategy; and as a philosophy) are described. The second part identifies common misconceptions - traps into which the general practitioners may fall when taking their stand on primary health care. In the third part, a blueprint for transforming the current systems of primary medical care systems into primary health care systems is outlined. The final section suggests some concrete actions to be taken by the general practitioners in implementing this blueprint.     

Mental Health Nurse Incentive Program: Facilitating physical health care for people with mental illness?

People with serious mental illness have increased rates of physical ill‐health and reduced contact with primary care services. In Australia, the Mental Health Nurse Incentive Program (MHNIP) was developed to facilitate access to mental health services. However, as a primary care service, the contribution to physical health care is worthy of consideration. Thirty‐eight nurses who were part of the MHNIP participated in a national survey of nurses working in mental health about physical health care. The survey invited nurses to report their views on the physical health of consumers and the regularity of physical health care they provide. Physical health‐care provision in collaboration with general practitioners (GPs) and other health‐care professionals was reported as common. The findings suggest that the MHNIP provides integrated care, where nurses and GPs work in collaboration, allowing enough time to discuss physical health or share physical health activities. Consumers of this service appeared to have good access to physical and mental health services, and nurses had access to primary care professionals to discuss consumers’ physical health and develop their clinical skills in the physical domain. The MHNIP has an important role in addressing physical health concerns, in addition to the mental health issues of people accessing this service.     

Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities.
Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny.
Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.     

General practitioners' perceptions of community psychiatric nurses in primary care

The management of and responsibility for the care of people with mental health problems in the community is increasingly being assumed by general practitioners (GPs) and primary care personnel. As primary care groups (PCGs) evolve, so must their expertise in managing people with a wide range of mental health problems. It is expected that all mental health professionals will participate in this development, although it is likely that community psychiatric nurses (CPNs) will be the largest professional group involved, with a significant part to play in the shaping, management and delivery of mental health services. To date, there has been little research into how CPNs are perceived by other primary health care professionals. This study seeks to provide an insight into how GPs assess the contribution of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs favourably and consider that they have an important role to play. Greater involvement in primary care raises issues about the education and preparation of CPNs, their professional development and supervision needs.     

Community health service capacity in China: a survey in three municipalities

Rationale China is reforming its health care system. It aims to strengthen primary health care through building community health facilities and assigning a ‘gate‐keeper’ role to primary care providers. However, it remains unknown whether community health facilities are able to fulfil such a mission. This study evaluated the service capacity of a selected sample of community health facilities and the competency of primary care practitioners employed by those facilities. Methods Three municipalities from the east, middle and west of China were purposely selected. A questionnaire was undertaken in 45 randomly selected community health facilities in the three municipalities and 700 primary care practitioners responded to the survey. The survey investigated the capacity of the community health facilities in providing diagnostic services and the competency of the primary care providers in handling common health problems. Results The most common reasons for doctor–patient encounters were common cold and chronic diseases. The capacity of the community health facilities in providing diagnostic services was limited. Although the majority of respondents believed that they could correctly identify common symptoms, many were unable to perform some essential physical examinations. Conclusion The community health facilities are not able to fulfil their designated mission because of the limited diagnostic capacity and poor competency of the primary care practitioners. Priorities should be given to capacity building for the development of community health services in the future.     

GP group profiles and involvement in mental health care

Rationale and objectives Mental health is one of the leading causes of morbidity worldwide. Its impact in terms of cost and loss of productivity is considerable. Improving the efficiency of mental health care system has thus been a high priority for decision makers. In the context of current reforms that privilege the reinforcement of primary mental health care and integration of services, this article brings new lights on the role of general practitioners (GPs) in managing mental health, and shared‐care initiatives developed to deal with more complex cases. The study presents a typology of GPs providing mental health care, by identifying clusters of GP profiles associated with the management of patients with common or serious mental disorders (CMD or SMD). Methods GPs in Quebec (n = 398) were surveyed on their practice, and socio‐demographic data were collected. Results Cluster analysis generated five GP profiles, including three that were closely tied to mental health care (labelled, respectively: group practice GPs, traditional pro‐active GPs and collaborative‐minded GPs), and two not very implicated in mental health (named: diversified and low‐implicated GPs, and money‐making GPs). Conclusion The study confirmed the central role played by GPs in the treatment of patients with CMD and their relative lack of involvement in the care of patients with SMD. Study results support current efforts to strengthen collaboration among primary care providers and mental health specialists, reinforce GP training, and favour multi‐modal clinical and collaborative strategies in mental health care.     

Nurse practitioners substituting for general practitioners: randomized controlled trial

Title.  Nurse practitioners substituting for general practitioners: randomized controlled trial.
Aim.  This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact.
Background.  Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in the Netherlands, a Dutch trial was conducted.
Methods.  A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations.
Findings.  In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in the Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer.
Conclusion.  Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.     

Primary health care practitioners' tools for mental health care

The purpose of this study was to describe and analyse the content of mental health care from the practitioner's point of view. The specific aim of this paper was to outline the types of mental health care tools and the ways in which they are used by primary health care practitioners. The data were derived from interviews with doctors and nurses (n = 29) working in primary health care in six different health care centres of the Pirkanmaa region in Finland. The data were analysed by using qualitative content analysis. The tools of mental health care used in primary health care were categorized as communicative, ideological, technical and collaborative tools. The interactive tools are either informative, supportive or contextual. The ideological tools consist of patient initiative, acceptance and permissiveness, honesty and genuineness, sense of security and client orientation. The technical tools are actions related to the monitoring of the patient's physical health and medical treatment. The collaborative tools are consultation and family orientation. The primary health care practitioner him/herself is an important tool in mental health care. On the one hand, the practitioner can be categorized as a meta-tool who has control over the other tools. On the other hand, the practitioner him/herself is a tool in the sense that s/he uses his/her personality in the professional context. The professional skills and attitudes of the practitioner have a significant influence on the type of caring the client receives. Compared with previous studies, the present informants from primary health care seemed to use notably versatile tools in mental health work. This observation is important for the implementation and development of mental health practices and education.     

Identifying patterns in primary care consultations: a cluster analysis

Background  A literature review revealed that little is known about the systems context of general practice consultations and their outcomes.
Objectives  To describe the systems context and resulting underlying patterns of primary care consultations in a local area.
Design  Cross-sectional multi-practice study based on a three-part questionnaire. Cluster analysis of data.
Setting  Stratified random sample of general practices and general practitioners – NSW-Central Coast, Australia.
Participants  A total of 1104 adults attending 12 general practitioners between February and November 1999.
Results and Conclusions  The study identified seven subgroups within the study population uniquely defined by variables from the health system, individual doctor and patient, consultation and consultation outcomes domains. A systems approach provides a framework in which to track and consider the important variables and their known and/or expected workings and thus offer a contextual framework to guide primary care reform.     

Placing empowerment research within an action research typology

The focus of this paper is to use three action research typologies to consider retrospectively, and understand, the processes of an empirical study. The typologies are used to plot the changing emphasis of collaborative action research with a primary health care team that addressed their health promotion practice. The study implemented self-efficacy theory into the health promotion practice of a primary health care team and developed a self-efficacy framework for smoking cessation. The framework had some success in aiding practitioners in their work despite the patients' disinterest in smoking cessation. Two action research types can be identified within the study, a technical/experimental approach which surrounded the use of a researcher-led theoretical agenda, whereas the research facilitation was informed by critical theory and was classified as an enhancement/empowering action research type. This paper demonstrates the conflicting natures of these types which, in this study, resulted in positive outcomes associated with the experimental/technical approach but only at the expense of professional empowerment. The findings of this study imply that theoretically-led empowering action research was an incompatible combination in this instance and this potential conflict needs to be addressed by researchers engaging in collaborative research relationships with practitioners.     

Community health care nursing in Rajasthan. A registered nurse's perspective

This study focused on the great shortage of registered nurses (RNs) in primary health care in Rajasthan, India. It dealt especially with the nurses' own opinions about working in primary health care and their reasons for not working in it. Nurses at different levels in the health care organization were interviewed. The study was based on interviews with six RNs individually, three groups of six to eight nursing students each, and three policy-making chief nurses individually. The Minister of Health in Rajasthan also participated in the study. The study showed that the reasons for the lack of RNs in community health care were as follows: a government policy decision to place less educated nurses in the communities; the great shortage of nurses in general; the system whereby a nurse is not able to choose her/his place of work; unwillingness on the part of the nurses to work in community health care because of the great security problems; lack of support from authorities and lack of equipment. In general, community health care nursing as a work area was despised by society at large in Rajasthan.     

Mental Health Link: the development and formative evaluation of a complex intervention to improve shared care for patients with long-term mental illness

Aims and objectives This study aims to develop an intervention and related conceptual framework for developing shared care for patients with long‐term mental illness, and to provide a case study of the development of a complex intervention in primary care. Methods A pragmatic iterative design involved a literature review and focus groups followed by a formative evaluation including reflection, questionnaires and interviews. General practices and associated community mental health teams in Southeast London were involved. Participants included community mental health workers, psychiatrists, practice nurses, general practitioners, managers and local experts with an interest in primary mental health care. Results The model for shared care includes the core components of improved communication together with the development of a register and database with systems for review and recall. Local needs assessment, audit, training and guidelines are complimentary components. The intervention, Mental Health Link, is a facilitated quality improvement programme which aims to expedite the development of services by bringing the teams together to agree on a model of shared care suited to local needs, skills and interests, and by supporting the development of practice systems. Conclusions A model for shared care needs to take into account interdependencies of the components as well as the relationship with the context. The heterogeneity of primary and community care need to be reflected in the development of complex interventions designed to enhance shared care. It is possible to develop a generalizable complex intervention which is sensitive to local circumstances.     

Primary Care and Mental Health: Overview of Integrated Care Models

Primary care nurse practitioners are in a visible and critical position to screen, diagnose, and treat common mental health conditions. Integrated care models occur on a continuum from simple communication between providers to fully integrated interprofessional teams. Regardless of integration model available to the primary care nurse practitioner, mental health disorders should be appropriately identified and treated using evidence-based approaches. This clinical feature introduces the primary care nurse practitioner to various integrated care models and provides a brief overview regarding screening, diagnostic, and intervention recommendations, as well as potential future directions for education, training, and research.     

Public Health Nurses' Vision of their Future Reflects Changing Paradigms

Health care over the past decade has undergone important changes that have implications for public health nursing. The focus of public health has expanded, as a result of the World Health Organization establishing the goal of "Health for All by the Year 2000," with its strategy of primary health care. To be active participants in this expansion, public health nurses must be more explicit about their current contributions to health care systems; develop nursing frameworks consistent with the systems' changing goals; and articulate their visions of the future. It is clear that the medical paradigm of health care services needs to change to one of primary health care. Based on results of a recent public health nursing research study, a conceptual framework for the future practice of public health nursing was developed .     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

Empowering practice nurses in the follow-up of patients with established heart disease: lessons from patients' experiences

This paper reports on the views of patients with established heart disease of a structured programme of follow-up care provided by practice nurses (PNs) in general practice in England. It is based on in-depth interviews with 22 patients receiving an integrated primary and secondary care intervention being developed and piloted for patients following heart attack or diagnosis of angina. Patients identified the important features of follow-up care to be easy access to a health professional who possessed knowledge and social and emotional skills. A range of views about the ability of PNs to provide such care emerged from patients' accounts. patients' perceptions about the seriousness of their condition and the way PN follow-up care was provided in practices emerged as important issues affecting patients' views. In addition, perceptions about the practice nurse's role, status and knowledge, existing relationships with general practitioners, and issues of communication were also important factors. It is concluded that in order to develop high-quality PN-led services for patients with established heart disease, four issues need to be taken into account: practice nurse training; continuity of follow-up care; the integration of the primary and secondary care interface; and development of the practice nurse's status within the primary health care team.     

Nurses and English primary care groups: their experiences and perceived influence on policy development

AIMS OF THE STUDY: To investigate the experiences and perceived influence of nurses serving on English primary care group boards. BACKGROUND: The development of the nursing workforce and nursing services in primary care have been piecemeal and nurses have not always contributed to policy development. The recent establishment of primary care groups (PCGs) in the United Kingdom (UK) potentially offers nurses the opportunity to take a concerted and strategic role in developing professional roles and planning service developments. RESEARCH METHODS: As part of a longitudinal study of a 15% random sample of English primary care groups, nurse board members were surveyed in the winter of 1999. One hundred and forty-four nurses were invited to return self-completion questionnaires. RESULTS: Completed questionnaires were returned by 106 of those invited to participate (73%). Respondents reported that combining their usual work with their role in the PCG was frequently difficult. Only 26% perceived that they had been well prepared for their new role. Compared with other board members [for example, general practitioners (GPs)], nurses perceived that their own influence was limited, with only a quarter rating the influence of nurses on decision-making as great. Most of the sample were feeding back information to other primary care and community nurses working in the locality and 52% rated communication with this wider constituency as good or better. Nurse board members were enthusiastic about their role and optimistic about the positive future impact of PCGs on health. CONCLUSIONS: PCGs are still at a relatively early stage in their development. It is still too early to assess their impact on nurses working in primary care and community settings. Board membership offers nurses a voice in local health policy development.     

Why are we hiding? A qualitative exploration of New Zealand acupuncturists views on interprofessional care

BackgroundIn recent years more health service users are utilising complementary and alternative medicine (CAM), including acupuncture, for the management of their health. Currently general practitioners (GPs), in most cases, act as the primary provider and access point for further services and also play an important role in integrated care management. However, the interaction and collaboration between GPs and acupuncturists in relation to shared care has not been investigated.This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article reports specifically the acupuncturists’ viewpoints.MethodsThis study formed part of a larger mixed methods trial investigating barriers and facilitators to communication and collaboration between acupuncturists and general practitioners in New Zealand. Semi structured interviews of 13 purposively sampled acupuncture participants were conducted and analysed using thematic analysis.ResultsThe data analysis identified both facilitators and barriers to integrative care. Facilitators included a willingness to engage, and the desire to support patient choice. Barriers included the limited opportunities for sharing of information and the lack of current established pathways for communication or direct referrals. The role evidence played in integrative practice provided complex and contrasting narratives.ConclusionsThis research contributes to the body of knowledge concerning communication and collaboration between GPs and acupuncturists, and suggests that by facilitating communication and collaboration, acupuncture can provide a significant component of integrated care packages. This research provides context within a New Zealand health care setting, and also provides insight through the disaggregation of specific provider groups for analysis, rather than a grouping together of CAM as a whole.     

Characteristics of severely mentally ill patients in and out of contact with community mental health services

Community mental health nurses have been criticized for failing to prioritize work with people with a severe or enduring mental illness, many of whom have no contact with specialist mental health services and rely entirely on their general practitioner and primary care team. It is important to ensure that those in contact with specialist services actually need this level of input but, conversely, that those in contact with only primary care receive a service that is equipped to meet their needs. This study examines the differences between these two groups of patients. A sample of 253 community-based patients with a severe or enduring mental illness was divided into those with mental health service contact and those without. Differences in the demographic characteristics of the two groups were assessed and further, more detailed, comparisons were made with a sub-sample of 49 individuals randomly drawn from this larger sample. Instruments adopted for these purposes comprised the Camberwell Assessment of Need and the Life Fulfilment Scale. It was found that patients with a psychotic disorder were more likely than those with neurosis to be in contact with mental health services and patients with schizophrenia were significantly more likely to be on the active caseload of a community mental health nurse than those from all other diagnostic groups. However, patients' levels of need, unmet need and quality of life did not differ in relation to their service contact. Whilst the study provides limited evidence that community mental health nurses are targeting people with the most serious disorders, questions remain about the large proportion not receiving specialist care. Because primary care plays a significant role in the care of severely mentally ill people living in the community, the further mental health training of general practitioners and practice nurses is becoming increasingly important.