Accessing out-of-hours care following implementation of the GMS contract: an observational study.

BACKGROUND: There is widespread concern that the quality of out-of-hours primary care for patients with complex needs may be at risk now that the new general medical services contract (GMS) has been implemented. AIM: To explore changes in the use of out-of-hours services around the time of implementation of the new contract for patients with complex needs, using patients with cancer as an example. DESIGN OF STUDY: Longitudinal observational study. SETTING: Out-of-hours primary care provider covering Devon (adult population 900,000), UK. METHOD: Two, 1-year periods corresponding to pre- (April 2003 to March 2004) and post-contract implementation (October 2004 to September 2005) were sampled. Call rates per 1000 of the adult population (age>or=16 years) were calculated for all calls (any cause) and cancer-related calls. Anonymised outcome and process measures data were extracted. RESULTS: Although overall call rates per 1000 population had increased by 26% (185 pre-contract to 233 post-contract), the proportion of cancer-related calls remained relatively constant (2.08% versus 1.96%). Around half (56%) of these callers had advanced cancer needs (including palliative care). By post-contract, the time taken to triage had significantly increased (P<0.001). Although the proportions admitted to hospital or receiving a home visit remained constant, calls where a special message was sent by the out-of-hours clinician to the in-hours team had decreased (P<0.001). CONCLUSION: The demand for out-of-hours care for patients with cancer did not alter disproportionately after implementation of the contract. While potential quality indicators (for example, hospital admissions, home visiting rates) remained constant, potentially adverse changes to triage time and communication between out-of-hours and in-hours clinicians were observed. Quality standards and provider databases require further refinement to capture elements of care relevant to patients with complex needs.     

A qualitative study exploring variations in GPs' out-of-hours referrals to hospital.

BACKGROUND: There is evidence of significant variations in hospital referral rates for GPs working in out-of-hours care. AIMS: To explain why there are marked variations in hospital referral rates for GPs working in out-of-hours care. DESIGN OF STUDY: In depth, face-to-face interviews with a purposive sample of GPs with different out-of-hours referral rates. SETTING: Bristol, UK. METHOD: GPs were selected according to their rate of out-of-hours hospital referral. They were classified as high, medium, or low referrers. Five interviews were carried out with GPs from each of the three categories. RESULTS: High referring GPs are typically cautious and believe it is better to admit if in doubt. They express anxiety about the consequences of a decision not to admit, both for the patient and for themselves. They hold negative attitudes towards alternatives to hospital admission. Low referrers were more confident about their decisions and less often worried afterwards. Low referrers were positive about alternatives to hospital admission and described themselves as able to resist pressures from family or carers to have someone admitted. Low referrers also see hospitals as places to be avoided and viewed their goal as preventing an admission. CONCLUSION: Educational programmes need to be developed to improve GPs' judgements of their competences and to build appropriate levels of confidence.     

Users' reports and evaluations of out-of-hours health care and the UK national quality requirements: a cross sectional study

Background

National standards for delivery of out-of-hours services have been refined. Health service users'' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs.

Aim

To investigate NHS service users'' reports and evaluations of out-of-hours care in the light of UK national service quality requirements.

Design

Cross sectional survey.

Setting

Three areas (Devon, Cornwall, Sheffield) of England, UK.

Method

Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users'' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment (‘call back time’); the time waiting for a home visit; and the waiting time at a treatment centre.

Results

UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of ‘up to an hour’), only one-third of users reported this as ‘excellent’. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as ‘excellent’, this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes.

Conclusion

Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of ‘good’ quality by service users. Attaining ‘excellent’ levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users'' expectations as well as their experience of care.     

Effect of the new contract on GPs' working lives and perceptions of quality of care: a longitudinal survey.

BACKGROUND: An ambitious pay-for-performance system was implemented in UK general practice in 2004 amid doubts that it could improve both the working lives of doctors and quality of care. AIM: To evaluate doctors' perceptions of their working lives and quality of care before and after the new contract. DESIGN OF STUDY: Longitudinal questionnaire survey. SETTING: England, UK. METHOD: A longitudinal postal survey of English GPs in February 2004 and September 2005. Measures included reported job satisfaction (7-point scale), hours worked, income, and impact of the contract. RESULTS: Responses were available from 2105 doctors in 2004 and 1349 in 2005. Mean overall job satisfaction increased from 4.58 out of 7 in 2004 to 5.17 in 2005. The greatest improvements in satisfaction were with remuneration and hours of work. Mean reported hours worked fell from 44.5 to 40.8. Mean income increased from an estimated 73,400 pounds in 2004 to 92,600 pounds in 2005. Most GPs reported that the new contract had increased their income (88%), but decreased their professional autonomy (71%), and increased their administrative (94%) and clinical (86%) workloads. After the introduction of the contract doctors were more positive than they had anticipated about its impact on quality of care. CONCLUSION: GPs' job satisfaction increased after the introduction of the new contract, despite perceptions of negative consequences for workload and autonomy. GPs reported working fewer hours with a higher income, and their expectations regarding the impact of the contract on quality of care had been exceeded.     

The UK's dysfunctional relationship with medical migrants: the Daniel Ubani case and reform of out-of-hours services

In 2008, a patient died in the UK after being given an excessive dose of diamorphine by an overseas-trained doctor working in out-of-hours (OOH) primary care. This incident led to a debate on the recourse to international medical graduates and on the shortcomings of the OOH system. It is argued here that a historical reflection on the ways in which the NHS uses migrant labour can serve to reframe these discussions. The British Medical Association, the General Medical Council, and the House of Commons Health Committee have emphasised the need for more regulation of overseas graduates. Such arguments fit into a well-established pattern of dependency on and denigration of overseas graduates. They give insufficient weight to the multiple systemic failings identified in reports on OOH provision by the Department of Health and the Care Quality Commission. Medical migrants are often found in under-resourced and unpopular parts of healthcare systems, in the UK and elsewhere. Their presence provides an additional dimension to Julian Tudor Hart''s inverse care law: the resources are fewer where the need is greatest, and the practitioner dealing with the consequences is more likely to be a migrant. The failings of the UK OOH system need to be understood in this context. Efforts to improve OOH care should be focused on controlling quality rather than the movement of doctors. A wider reflection on the nature of the roles that international medical graduates are asked to play in healthcare systems is also required.     

Risk taking in general practice: GP out-of-hours referrals to hospital

Background

Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.

Aim

To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.

Design of study

Cross-sectional comparison of admission rates; postal survey.

Setting

Three OOH providers in south-west England.

Method

Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.

Results

There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).

Conclusion

GPs'' threshold of risk is important for explaining variations in referral to hospital.     

Streamline triage and manage user expectations: lessons from a qualitative study of GP out-of-hours services

Background

Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users'' needs and expectations.

Aim

To explore users'' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign.

Setting

Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales.

Participants

Sixty recent service users or carers (20 in each location).

Method

Semi-structured telephone interviews; thematic analysis.

Results

Users'' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision.

Conclusion

Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.     

Does distance matter? Geographical variation in GP out-of-hours service use: an observational study

BACKGROUND: GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services. AIM: To examine the effects of distance and rurality on rates of out-of-hours service use. DESIGN OF STUDY: Geographical analysis based on routinely collected data on telephone calls in June (n=14 482) and December (n=19 747), and area-level data. SETTING: Out-of-hours provider in Devon, England serving nearly 1 million patients. METHOD: Straight-line distance measured patients' proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004). RESULTS: Call rates decreased with increasing distance: 172 (95% confidence interval [CI]=170 to 175) for the first (nearest) distance quintile, 162 (95% CI=159 to 165) for the second, and 159 (95% CI=156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0-4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas. CONCLUSION: There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.     

Patients' involvement in decisions about medicines: GPs' perceptions of their preferences.

BACKGROUND: Patients vary in their desire to be involved in decisions about their care. AIM: To assess the accuracy and impact of GPs' perceptions of their patients' desire for involvement. DESIGN OF STUDY: Consultation-based study. SETTING: Five primary care centres in south London. METHOD: Consecutive patients completed decision-making preference questionnaires before and after consultation. Eighteen GPs completed a questionnaire at the beginning of the study and reported their perceptions of patients' preferences after each consultation. Patients' satisfaction was assessed using the Medical Interview Satisfaction Scale. Analyses were conducted in 190 patient-GP pairs that identified the same medicine decision about the same main health problem. RESULTS: A total of 479 patients participated (75.7% of those approached). Thirty-nine per cent of these patients wanted their GPs to share the decision, 45% wanted the GP to be the main (28%) or only (17%) decision maker regarding their care, and 16% wanted to be the main (14%) or only (2%) decision maker themselves. GPs accurately assessed patients' preferences in 32% of the consultations studied, overestimated patients' preferences for involvement in 45%, and underestimated them in 23% of consultations studied. Factors protective against GPs underestimating patients' preferences were: patients preferring the GP to make the decision (odds ratio [OR] 0.2 per point on the five-point scale; 95% confidence interval [CI] = 0.1 to 0.4), and the patient having discussed their main health problem before (OR 0.3; 95% CI = 0.1 to 0.9). Patients' educational attainment was independently associated with GPs underestimation of preferences. CONCLUSION: GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when patients have not consulted about their condition before.     

Operationalising unscheduled care policy: a qualitative study of healthcare professionals’ perspectives

Background

UK health policy aims to reduce the use of unscheduled care, by increasing proactive and preventative management of patients with long-term conditions in primary care.

Aim

The study explored healthcare professionals’ understanding of why patients with long-term conditions use unscheduled care, and the healthcare professionals’ understanding of their role in relation to reducing the use of unscheduled care.

Design and setting

Qualitative study interviewing different types of healthcare professionals providing primary care or unscheduled care services in northwest England.

Method

Semi-structured interviews were conducted with 29 healthcare professionals (six GPs; five out-of-hours GPs; four emergency department doctors; two practice nurses; three specialist nurses; two district nurses; seven active case managers). Data were analysed using framework analysis.

Results

Healthcare professionals viewed the use of unscheduled care as a necessary component of care for patients with long-term conditions. Those whose roles involved working to targets to reduce the use of unscheduled care described a tension between this and delivering optimum patient care. Three approaches to reducing unscheduled care were described: optimising the system; negotiating the system; and optimising the patient.

Conclusion

Current policy to reduce the use of unscheduled care does not take account of the perceptions of the healthcare professionals who are expected to implement them. Lipsky’s theory of street-level bureaucrats provides a framework to understand how healthcare professionals respond to imposed policies. Healthcare professionals did not see the use of unscheduled care as a problem and there was limited commitment to the policy targets. Therefore, policy should aim for whole-system change rather than reliance on individual healthcare professionals to make changes in their practice.     

Individual influences on lifestyle change to reduce vascular risk: a qualitative literature review

Background

Management of cardiovascular risk includes adoption of healthy lifestyles. Uptake and completion rates for lifestyle programmes are low and many barriers and facilitators to lifestyle behaviour change have been reported in the literature. Clarity on which barriers and facilitators to target during consultations in primary care may support a more systematic approach to lifestyle behaviour change in those at high risk of cardiovascular events.

Aim

To identify the main barriers and facilitators to lifestyle behaviour change in individuals at high risk of cardiovascular events.

Design

A content synthesis of the qualitative literature reporting patient-level influences on lifestyle change.

Method

Qualitative studies involving patients at high risk of cardiovascular events were identified through electronic searching and screening against predefined selection criteria. Factors (reported influences) were extracted and, using a clustering technique, organised into categories that were then linked to key themes through relationship mapping.

Results

A total of 348 factors were extracted from 33 studies. Factors were organised into 20 categories and from these categories five key themes were identified: emotions, beliefs, information and communication, friends and family support, and cost/transport.

Conclusion

It is possible to organise the large number of self-reported individual influences on lifestyle behaviours into a small number of themes. Further research is needed to clarify which of these patient-level barriers and facilitators are the best predictors of uptake and participation in programmes aimed at helping people to change lifestyle.     

Practice size and service provision in primary care: an observational study

Background

In 2004, primary care payments for basic services and enhanced services were separated. This change has greatly facilitated the evaluation of the breadth and volume of services.

Aim

To determine whether larger practices produce a higher volume and greater diversity of enhanced services.

Design of study

Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000.

Setting

A total of 384 practices in 14 English primary care trusts.

Method

Practice data for all practices were collated for enhanced services, practice size, and deprivation. Diversity and volume of enhanced services were used as dependent variables in a series of multiple regression models to ascertain the effect of practice size, and any relationship with deprivation.

Results

Larger practices provided a greater diversity of services (P = 0.002), although this effect was not present in practices with more than 6330 patients. Practice size seems to influence the volume of enhanced services in general medical services, but this effect disappeared when deprivation was taken into account. Deprivation had a negative influence on the volume of enhanced services provided (P = 0.019). The effect of deprivation on volume persisted in practices with more than 6330 patients.

Conclusion

Current average-sized practices provide similar volume and diversity of enhanced services as those in the largest quartile; therefore, there seems to be little merit in creating ‘supersurgeries’ if the aim is to transfer work from secondary to primary care. There does not seem to be an upper threshold above which practice size creates spare capacity and expertise to deliver a significantly greater volume or more diversity of extra services.     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

GPs' approach to insulin prescribing in older patients: a qualitative study

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.     

GPs' views in five European countries of interventions to promote prudent antibiotic use

Background

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

Aim

To explore GPs'' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

Design and setting

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

Method

Fifty-two semi-structured interviews explored GPs'' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

Results

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

Conclusion

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.     

The nature of informational continuity of care in general practice

Background

The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.

Aim

To answer the question ‘How is informational continuity developed in general practice?’.

Design of study

A rigorous systematic review of relevant electronic databases.

Method

Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.

Results

Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.

Conclusion

These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.     

Asylum seekers,refugees, and the politics of access to health care: a UK perspective

The UK government has recently consulted on proposals to prohibit access to health care for some asylum seekers. This discussion paper considers the wider ethical, moral, and political issues that may arise from this policy. In particular, it explores the relationship between immigration and health and examines the impact of forced migration on health inequalities. It will be argued that it is both unethical and iniquitous to use health policy as a means of enforcing immigration policy. Instead, the founding principle of the NHS of equal access on the basis of need should be borne in mind when considering how to meet the needs of this population.     

Rude or aggressive patient behaviour during out-of-hours GP care: Challenges in communication with patients

Objective

GPs in out-of-hours care report that they feel at risk of rude or aggressive patient behaviour. We tried to get information about the incidence, types and patient characteristics of rude or aggressive behaviour.

Methods

Retrospective, observational study involving the analysis of medical records of all patients who contacted a Dutch GP cooperative between June 2001 and June 2002.

Results

Of the 36,259 patient records, 545 (1.5%) reported rude behaviour, 67 (0.2%) reported verbal aggression and physical aggression was not reported. Anxiety, sorrow, or pain was reported by patients in 49.7% of the cases with rude or aggressive behaviour. The conflict topic between patients and professional was mostly the request of a home visit (21.8%), or a centre consultation (17.3%). Patients with mental health problems (OR 2.3 CI 1.8–3.1) were more at risk for rude or aggressive behaviour.

Conclusion

Rude and aggressive behaviour on GP cooperatives occurs relative seldom and is associated with anxiety, sorrow, and pain. The wish to see a doctor instead getting a telephone advice is a frequent conflict topic between patient and professional.

Practice implications

The findings suggest that improved communication at the telephone, particularly exploring the expectation, needs and worries of patients, may reduce aggressive behaviour.