Sustaining complementary therapy provision in primary care: lessons from existing services

OBJECTIVE: To examine factors which sustain complementary therapy services in primary care in order to inform policy making in a context of rapid change. DESIGN: In-depth qualitative case studies, including semi-structured interviews with key informants. SETTING: 10 existing schemes of complementary therapy provision in primary care across England. RESULTS: GPs and complementary practitioners reported wide-ranging benefits from complementary therapy provision in primary care. However, they felt that their ability to sustain complementary therapy provision was mediated by a) funding, b) the need for research, and c) appropriate service delivery mechanisms. a) Many schemes were the result of and sustained by personal vision. As such they had negotiated a variety of funding sources over a considerable period, against a background perception that continued funding was uncertain. b) Most informants believed that more research was needed to provide a solid evidence base for service continuation and development, in particular clinical and cost-effectiveness work. c) The manner of service delivery, notably whether a service was located within a general practice or in a referral centre, was seen as having implications for the integration of practitioners and for patient access to services. CONCLUSIONS: Current complementary therapy provision in primary care has developed on an 'ad hoc' basis. In particular, the existence of GP fundholding in the 1990s, in which primary care physicians were able to purchase health services on a practice basis, facilitated the development of services in this way. Within the current Primary Care Group context, where purchasing decisions are made collectively by a group of general practices within a region, consideration needs to be given to both the continuity of schemes already in existence and to whether a more standardized approach to service development will be required to facilitate sustainable provision.     

Improving health and care for patients by redesigning services: the development and implementation of a clinical assessment service in Harrow Primary Care Trust

The redesign of healthcare services in Harrow Primary Care Trust is due to a number of drivers including: centrally imposed targets as outlined in various policy documents; shifting the balance of care; service delivery in a challenging financial climate; response to national consultations which indicate that patients want services nearer to home; and local and national knowledge of providing different types of services. A local enhanced scheme was devised by the trust to support general practitioners to follow care pathways using evidence-based literature, best practice and discussions with clinicians, nurses and patient representatives. The result was an ambitious and innovative service which has attracted attention from neighbouring London primary care trusts, which are seeking to replicate the model.     

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.     

Feasibility and acceptability of providing nurse counsellor genetics clinics in primary care

AIM: This paper reports a pilot study to test the feasibility of providing genetic nurse counsellor clinics in primary care in the United Kingdom, to develop a questionnaire to evaluate patients' satisfaction with their genetics appointments, and to establish patient and provider costs. BACKGROUND: Genetic counsellors are healthcare professionals with experience in medical genetics and counselling and often have a professional background in nursing, science, genetics, psychology, or public health and work as members of multidisciplinary teams. Professional genetic counsellor accreditation is possible in the United Kingdom, United States of America, Australia and Canada. Increasing referrals to specialist genetics services have precipitated a review of models of service delivery in the United Kingdom. METHODS: A random half of 74 general practices in three primary care trusts were selected for the study, and the patients registered with these practices and referred to the clinical genetics service, were offered an appointment in primary care with a genetic nurse counsellor. A clinic follow-up postal questionnaire was developed. RESULTS: Between July 2002 and May 2003, 64 appointments were offered to patients referred and registered with the selected general practices, 45 (79%) patients attended their appointment and 34 (77%) returned their follow-up questionnaire. Total mean satisfaction score was high and patients were most satisfied with the information and affective domains of the appointment. Those referred with a family history of cancer were more satisfied than those referred with a non-cancer diagnosis. Forty-eight per cent of patients seen by the genetic nurse counsellor did not need to attend a further appointment with a doctor in secondary care. Patients were satisfied with the travel time and distance to clinic and patient clinic costs were low. CONCLUSION: Patients do attend genetic nurse counsellor clinics in primary care, and are satisfied with the new location. A large cluster randomized controlled trial is now being conducted to obtain a controlled comparison of clinic attendance rates and patients' satisfaction with clinics in primary vs. secondary care settings.     

Residential Treatment of Substance Abusing Adolescents: Trends in the Post-Managed Care Era

ABSTRACT

This paper explores historical and recent trends in the delivery of residential adolescent substance abuse treatment, looking specifically at the impact of managed care on the service delivery system. Three historical eras are conceptualized by the authors: (1) an era prior to managed care in which services were provided on a fee for service basis by health insurance companies and lengths of stay were relatively longer; (2) an era of managed care in which services were funded through managed care organizations and lengths of stay were significantly reduced; and (3) the current era in which residential services are provided through self-pay and through other service systems. Awareness of these changes is important for all practitioners who provide services to adolescents and demonstrate the need to advocates for residential substance abuse services for all adolescents.     

Relationship between use of increased primary health care and other out-patient care in a Swedish urban area. I. Utilisation of public primary health care

The Swedish National Health and Medical Care program is currently undergoing a change. The aim of this gradual change is a more decentralized system where the primary care service is expanded to cater for the transfer of patients from the hospitals over to primary care. This study, which is one part of a longitudinal design aims to show changes in public utilization of the services of general practitioners and district nurses after the expansion of the Matteus Primary Health Care Centre (MPHCC), city of Stockholm. The analysis is based partly on the annual statistical records and partly on medical chart studies of visits to the general practitioner by a selected population. The results showed that the population in the study district made twice as many visits to general practitioners and district nurses after the establishment of the MPHCC. It was also shown that the number of individuals visiting the general practitioners more than doubled during an 18-month period following the expansion of MPHCC. These results corresponds well with the aims associated with the expansion in primary care in future medical care services.     

Advanced nursing practice in paediatric critical care

Following the successful implementation of High Dependency Care: a model for development at King's College hospital in 2005, the authors wished to consider the addition of a fourth tier to the model. A review of the clinical environment was undertaken and it was suggested that the introduction of an advanced nurse practitioner could contribute to the education and continuation of the outreach service detailed in the model, as well as to the improvement of critical care services and career development opportunities for nurses within the unit. A survey was undertaken to identify the views of medical and nursing staff about essential roles and responsibilities of advanced nurse practitioners in this area. This would then direct the development of a teaching and competency programme that could promote advanced practice in the critical care environment. There was no consensus on the tasks advanced nurse practitioners can undertake, the appropriate mentors in the clinical environment, the level of education they must achieve, nor the time in which this should be completed. There was confusion about the qualifications required for advanced nursing practice, mentorship and training. However, there was support for this role and respondents confirmed the view that advanced nursing practiced would be beneficial in patient care delivery.     

Critical care outreach: the need for effective decision-making in clinical practice (Part 1).

Since the publication of 'Comprehensive Critical Care' (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision 'without walls'. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services.     

Primary health care needs of persons with physical disabilities: what are the research and service priorities?

The three-stage Delphi method was used to build consensus among experts in primary care and disability on research and service priorities in the area of primary health care for persons with physical disabilities. The specific areas of focus were (1) the high rate of rehospitalization, (2) health issues associated with aging, (3) problems of access to primary care, and (4) innovative organizational approaches to financing and providing primary care services. Issues concerning personal attendant/home health care were ranked highly in all four areas and were especially dominant in the area of rehospitalization. The issue of coordinated health care management received high ratings as well, especially in the "access" area. Other prominent issues included the effects of insurance coverage and the training of primary care providers in disability-related primary care. There was a high degree of correlation between the rankings of physicians and nonphysicians, especially in the areas of hospitalization, aging, and access. This paper examines directions in which future research and service efforts should be focused.     

Facilitating an integrated approach to primary health care in Saskatchewan

It is unlikely that truly integrated primary health care will become a reality unless health professionals actively strive to foster integration. Dialogue about integration barriers and opportunities has begun between the nursing, pharmacy, social work, emergency medical services, and medical professions. This dialogue should be expanded to include all of the professions with a potential role in an integrated system. The dialogue will also need to include government leaders as key public policy decisions will significantly influence the success or failure of integrated primary health service delivery strategies. As well, dialogue needs to occur with communities so that citizens can understand, value and help shape and maintain this kind of service delivery. Public education needs to emphasize that an integrated approach to primary health care in Saskatchewan is the best kind of service that can be provided. The Integrated Primary Health Care Working Group believes that the principles of primary health care require health professionals in Saskatchewan to develop an integrated approach to health services delivery in Saskatchewan. An exploration of possible barriers to this integrated approach is an important first step in eliminating barriers and facilitating effective health care service delivery to meet population health needs.     

Patients' accounts of the differences in nurses' and general practitioners' roles in primary care

AIM: This paper reports a study of patients' accounts of the differences in nurses' and general medical practitioners' roles in primary care. BACKGROUND: Nurses are now diagnosing and treating illnesses including conducting first contact care consultations. However, the findings of international studies reporting patients' views of developments in nursing roles are not consistent. Whilst some studies report higher satisfaction following nurse consultations, others suggest that patients do not want nurses to replace general medical practitioners. Healthcare professionals' views of the boundaries of their roles have been studied, but patients' views have not been reported. METHOD: Semi-structured interviews were conducted with 28 adults attending general practices for urgent 'same day' appointments during 2004. Participants were interviewed prior to their consultation with either the nurse or general medical practitioner and 19 participants were interviewed after the consultation. Data collection and analysis were concurrent, and based on the constant comparative method. FINDINGS: Participants' views reflected traditional hierarchies in primary care. They preferred to consult with general medical practitioners if they perceived their symptoms to be serious and with nurses for minor symptoms and reassurance. They thought that nurses had more time for them and were more compassionate. Interpersonal/relational continuity of care was important and for most participants this was with a general medical practitioner who knew them. Participants trusted known practitioners; they also placed trust in professional groups and familiar structures such as the practice. CONCLUSION: New nursing services should incorporate patients' views on continuity of care provider when developing models of care delivery. Patient information leaflets in general practices should be used to explain the roles of general practitioners and nurse practitioners/practice nurses. As these roles develop further, more research is needed into all aspects of their implementation and patients' views should particularly be evaluated.     

Enabling legislation in diagnosis and prescribing of medicine by nurses/health practitioners

The South African health system has undergone major changes over the last 5-10 years. These rapid changes have not only significantly increased the visibility of the nurse practitioner in South Africa, but are also posing challenges to the profession and health care services that need to be addressed. In its Health Policies the Government has indicated that the nursing/midwifery profession, as the biggest group of health care professionals, should be the practitioners to provide primary health care services to the communities. But to do this, they require enabling legislation. The "permit system" has been in place for non-pharmacists and institutions other than hospitals and pharmacies to acquire, possess, use and supply medication for a number of years. This system has been fraught with problems mainly due to a lack of clarity on exactly how the system works and the system had been abused. The purpose of this article is to explore the current situation with the aim to analyze the legal framework that exists within which the primary health care services, and specifically the diagnosing and prescribing of medication, could be performed. The conclusion is made that health legislation has not kept up with the rapid changes in service delivery and are not adequate to empower the nurse to deliver health services. Some recommendations are made for the way forward.     

Striving for independence: experiences and needs of service users with life limiting conditions

Title.  Striving for independence: experiences and needs of service users with lifelimiting conditions.
Aim.  This paper is a report of a study to explore what service users with a range of life-limiting conditions identify as their key experiences and needs generally and, specifically, from health and social care services.
Background.  Whilst internationally palliative care has a primary focus on service users who have cancer, there is growing evidence that those with non-cancer life-limiting conditions have similar palliative care needs. The literature has mainly been focused on independence, choice and control at an individual level, with wider influences on the maintenance or attainment of independence ignored.
Method.  A participatory approach was used in 2003–2004, with both the researcher and a group of service users working together in all stages of the study. Twenty-five participants in receipt of support from an acute hospital, primary care, social services and a hospice took part. Face-to-face individual interviews and small discussion groups were conducted and data were analysed thematically.
Findings.  Eight different but interconnected themes were identified. Independence/dependence was an overarching theme, with negotiation between independence and dependence being evident across all themes. This theme and the influence of health and social care services on the experience of living with life-limiting conditions are the focus of this paper.
Conclusion.  Palliative care and practitioners should focus on maximizing independence at both the individual and structural levels. How services for those with life-limiting conditions are provided and relationships with health and social care staff can directly impact on an individual's experience of independence, choice and control.     

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.     

Improving delivery of primary care for vulnerable migrants: Delphi consensus to prioritize innovative practice strategies

Objective

To identify and prioritize innovative strategies to address the health concerns of vulnerable migrant populations.

Design

Modified Delphi consensus process.

Setting

Canada.

Participants

Forty-one primary care practitioners, including family physicians and nurse practitioners, who provided care for migrant populations.

Methods

We used a modified Delphi consensus process to identify and prioritize innovative strategies that could potentially improve the delivery of primary health care for vulnerable migrants. Forty-one primary care practitioners from various centres across Canada who cared for migrant populations proposed strategies and participated in the consensus process.

Main findings

The response rate was 93% for the first round. The 3 most highly ranked practice strategies to address delivery challenges for migrants were language interpretation, comprehensive interdisciplinary care, and evidence-based guidelines. Training and mentorship for practitioners, intersectoral collaboration, and immigrant community engagement ranked fourth, fifth, and sixth, respectively, as strategies to address delivery challenges. These strategies aligned with strategies coming out of the United States, Europe, and Australia, with the exception of the proposed evidence-based guidelines.

Conclusion

Primary health care practices across Canada now need to evolve to address the challenges inherent in caring for vulnerable migrants. The selected strategies provide guidance for practices and health systems interested in improving health care delivery for migrant populations.     

Improving the physical health-mental health interface for the chronically mentally ill: could nurse case managers make a difference?

Although the increased incidence and prevalence of medical illnesses among the chronically mentally ill has been well documented, access and use of general health care services by this population remains problematic despite the implementation of case management. This article describes the problems experienced in meeting physical health care needs through the five core case-management components of client identification and outreach, assessment, service planning, monitoring of service delivery, and advocacy. A model of case management is proposed that uses psychiatric nurse clinical specialists in supervisory and consultative r?les, and nurse practitioners to deliver primary care.     

Race and preventive services delivery among black patients and white patients seen in primary care

BACKGROUND: Numerous studies have documented racial disparities in delivery of health care treatment services, but there is little information to determine whether similar disparities exist in the delivery of preventive services. OBJECTIVE: To determine if disparities exist in preventive service delivery to non-Hispanic white patients and black patients in primary care. RESEARCH DESIGN: Multimethod study using direct observation of patient encounters, medical record review, and patient exit questionnaire. SUBJECTS: Four thousand three hundred thirteen outpatients presenting to 138 family physicians. MEASURES: Delivery of 15 screening, 24 health-habit counseling and 11 immunization services recommended by the US Preventive Services Task Force. RESULTS: Using multilevel linear regression analysis, no significant racial differences were found in rates of delivery of screening services or immunizations. However, black patients were more likely to receive preventive health-habit counseling (mean percent of patients up-to-date on all recommended counseling services, adjusted for covariates: 11.6% for black patients, 9.5% for whites, P = 0.003). CONCLUSIONS: Black patients able to access primary care receive preventive services at rates equal to or greater than white patients. This suggests that efforts to increase delivery of preventive care in black patients need to focus on access to primary care.     

Developing a palliative care outreach service

This article describes the development of a palliative care outreach service by two nurse practitioners into ten community hospitals. The service was designed to improve equity of service delivery in the area and to meet national initiatives aimed at developing palliative care services. It involved responding to direct referrals while developing an educational programme for staff members. The results of a survey, which identified achievements for patient care and staff development, are discussed.     

Interprofessional teamwork in comprehensive primary healthcare services: Findings from a mixed methods study

This article draws on data from a 5-year project that examined the effectiveness of Comprehensive primary healthcare (CPHC) in local communities. A hallmark of CPHC services is interprofessional teamwork. Drawing from this study, our article presents factors that enabled, or hindered, healthcare teams working interprofessionally in Australian primary healthcare (PHC) services. The article reports on the experiences of teams working in six Australian PHC services (four managed by state governments, one non-government sexual health organisation, and one Aboriginal community-controlled health service) during a time of significant health sector restructure. Findings are drawn from two key methods: an online survey of practitioners and managers (n = 154), and interviews with managers and practitioners (n = 60) from the six study sites. The majority of survey respondents worked with other health professionals in their service to provide interprofessional care to clients. Processes included formal team meetings, case conferencing, referring clients to other health professionals if needed, informal communication with other health professionals about clients, and team-based delivery of care. A range of interrelated factors affected interprofessional work at the services, from contextual, organisational, processual, and relational domains. Funding cuts and policy changes that saw a reorientation and re-medicalisation of South Australian services undermined interprofessional work, while a shared CPHC culture and commitment among some staff was helpful in resisting some of these effects. The co-location of services was a factor in PHC teams working interprofessionally and not only enabled some PHC teams to work more interprofessionally but also created barriers to interprofessional teamwork through disruption resulting from restructuring of services. Our study indicates the importance of decision makers taking into account the potential effects of policy and structural changes on interprofessional teamwork. Decision makers should strive to minimise unintended negative effects of changes on the functioning of interprofessional teams.