Satisfaction and adherence of patients with amputations to physiotherapy service at public hospitals in KwaZulu-Natal,South Africa

Background

Individuals who have undergone a lower limb amputation require comprehensive rehabilitation from the multidisciplinary team to ensure optimal treatment outcomes and social integration. Physiotherapists play a pivotal role within the multidisciplinary team and offer patients physical and psychosocial rehabilitative care. Determining patients'' satisfaction levels and exploring factors affecting adherence to physiotherapy interventions can inform practice and improve service delivery of rehabilitation within resource poor settings such as South Africa.

Objectives

To determine the level of satisfaction with physiotherapy services rendered to acute and sub-acute in-patients with lower limb amputations and to explore factors affecting adherence to physiotherapy intervention.

Methods

A prospective survey of 35 patients with lower limb amputations from four public hospitals in South Africa was undertaken. A modified version of the Hampstead rehabilitation centre patient satisfaction questionnaire was utilised.

Results

Majority of participants were satisfied with the physiotherapy services whilst a few reported dissatisfaction. Three themes emerged whilst exploring the patients'' experience relating to adherence to physiotherapy programmes. Themes included service delivery, patient-therapist interaction and participation barriers and facilitators.

Conclusion

Recommendations aimed to improve quality of care and healthcare outcomes thereby enhancing the participants'' adherence to the physiotherapy programme.     

The commercialisation of GP services: a survey of APMS contracts and new GP ownership

Background

Alternative provider of medical services (APMS) legislation enables private commercial firms to provide NHS primary care. There is no central monitoring of APMS adoption by primary care trusts (PCTs), the new providers, or market competition.

Aim

The aims were to: examine APMS contract data on bidders and providers, patient numbers, contract value, duration, and services; present a typology of primary care providers; establish the extent of competition; and identify which commercial providers have entered the English primary care market.

Design of study

Cross-sectional study.

Setting

All PCTs in England.

Method

A survey was carried out in March 2008 gathering information on the number of APMS contracts, their value and duration, patient numbers, the successful tender, and other bidders.

Results

A total of 141 out of 152 PCTs provided information on 71 APMS contracts that had been awarded and 66 contracts that were out to tender. Of those contracts awarded, 36 went to 14 different commercial companies, 28 to independent GP contractors, seven to social enterprises, and two to a PCT-managed service; one contract is shared by three different provider types. In more than half of the responses information on competition was not disclosed. In a fifth of those contracts awarded to the commercial sector, for which there is information on other bidders, there was no competition. Contracts varied widely, covering from one to several hundred thousand patients, with a value of £6000–12 million, and lasting from 1 year to being open-ended. Most contracts offered standard, essential, additional, and enhanced services; only a few were for specialist services.

Conclusion

The lack of data on cost, patient services, and staff makes it impossible to evaluate value for money or quality, and the absence of competition is a further concern. There needs to be a proper evaluation of the APMS policy from the perspective of value for money and quality of care, as well as patient access and coverage.     

Factors influencing professional decision making on unplanned hospital admission: a qualitative study

Background

Unplanned admissions to hospital are a challenge for healthcare systems internationally. In the UK variation in unplanned admission rates across geographical areas, general practices and GPs remains largely unexplained.

Aim

To identify factors influencing professional decision making around unplanned hospital admission.

Design and setting

Qualitative study with a purposive sample of health and social care professionals from three primary care trusts, two acute hospitals, social services and an ambulance service in the South West of England.

Method

Semi-structured interviews were conducted with 19 professionals. Interviews were audio-recorded and transcribed. Data were analysed thematically drawing on the constant comparative method.

Results

The main factors influencing professional decision making around unplanned admissions were: lack of availability of seamless care on a 24/7 basis; ‘professional tribalism’ and poor information flow; service targets and performance management; commissioning culture and the impact of a ‘market approach’; and clinical governance structures, tolerance of risk and the role of peer support. A tension was perceived between the need to reduce unplanned admissions by tolerating more risk in primary care and a risk averse culture in secondary and emergency care.

Conclusion

Professional decision making that leads to unplanned admission to hospital is influenced by a range of organisational and individual health or social care professional factors. Finding ways to modify and ameliorate the effects of these systems and individual influences should be considered an important goal in the design of new interventions.     

Integrating preconception care for women with diabetes into primary care: a qualitative study

Background

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

Aim

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

Design of study

Qualitative, cross-sectional study.

Setting

A London teaching hospital and GP practices in the hospital catchment area.

Method

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

Results

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs'' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP''s role presents a challenge to implementing ‘shared’ preconception care.

Conclusion

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study''s findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.     

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.     

Childhood long-term conditions in primary care: a qualitative study of practitioners’ views

Background

Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.

Aim

To explore practitioners’ views of supporting children with LTCs and their families in primary care.

Design and setting

Qualitative interview study in primary care settings in South Yorkshire, England.

Method

Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.

Results

Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.

Conclusion

Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners.     

Follow-up of cancer in primary care versus secondary care: systematic review

Background

Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care.

Aim

To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care.

Design of study

Systematic review.

Setting

Primary and secondary care settings.

Method

A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care.

Results

There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals.

Conclusion

Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached.     

Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation

Background

Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation.

Aim

To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for them and to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates.

Design and setting

Cohort study of a service intervention in a general practice and a primary care team in Scotland.

Method

The ACP sets out patients’ wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, which matched patients in two practices for age, sex, multiple morbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival.

Results

Survivors from the ACP cohort (n = 80) had 510 fewer days in hospital than in the 12 months pre-intervention: a significant reduction of 52.0% (P = 0.020). There were 37 fewer admissions of the survivors from that cohort post-intervention than in the preceding 12 months, with a significant reduction of 42.5% (P = 0.002). Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3 months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively).

Conclusion

This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit in managing end-of-life care.     

Does higher quality primary health care reduce stroke admissions? a national cross-sectional study

Background

Hospital admission rates for stroke are strongly associated with population factors. The supply and quality of primary care services may also affect admission rates, but there is little previous research.

Aim

To determine if the hospital admission rate for stroke is reduced by effective primary and secondary prevention in primary care.

Design and setting

National cross-sectional study in an English population (52 763 586 patients registered with 7969 general practices in 152 primary care trusts).

Method

A combination of data on hospital admissions for 2006–2009, primary healthcare staffing, practice clinical quality and access indicators, census sources, and prevalence estimates was used. The main outcome measure was indirectly standardised hospital admission rates for stroke, for each practice population.

Results

Mean (3 years) annual stroke admission rates per 100 000 population varied from zero to 476.5 at practice level. In a practice-level multivariable Poisson regression, observed stroke prevalence, deprivation, smoking prevalence, and GPs/100 000 population were all risk factors for hospital admission. Protective healthcare factors included the percentage of stroke or transient ischaemic attack patients whose last measured total cholesterol was ≤5 mmol/l (P<0.001), and ability to book an appointment with a GP (P<0.003). All effect sizes were relatively small.

Conclusion

Associations of stroke admission rates with deprivation and smoking highlight the need for smoking-cessation services. Of the stroke and hypertension clinical quality indicators examined, only reaching a total cholesterol target was associated with reduced admission rates. Patient experience of access to primary care may also be clinically important. In countries with well-developed primary healthcare systems, the potential to reduce hospital admissions by further improving the clinical quality of primary healthcare may be limited.     

Utilising out-of-hours primary care for assistance with cancer pain: a semi-structured interview study of patient and caregiver experiences

Background

Pain is the most frequent complication of cancer and an important reason for out-of-hours (OOH) primary care contacts by patients with established cancer. Existing quantitative data give little insight into the reason for these contacts. Exploring such encounters of care could highlight ways to improve anticipatory cancer care and communication between daytime and OOH primary care services.

Aim

To explore the experiences, views, and opinions of patients and their caregivers who have used OOH primary care for help with managing cancer pain.

Design and setting

A semi-structured interview study with patients and caregivers who have utilised an OOH primary care service in Grampian, Scotland, because of pain related to cancer.

Method

Semi-structured interviews with 11 patients and four caregivers (n = 15), transcribed verbatim and analysed using framework analysis and, to a lesser extent, inductive thematic analysis.

Results

Six key themes emerged: making sense of pain and predicting its likely course; beliefs about analgesics; priority daytime access; the importance of continuity of care and communication between all involved; barriers and facilitators to seeking help in the OOH period; and satisfaction/dissatisfaction with OOH care. Three prominent sub-themes were: patient knowledge; the influence of a caregiver on decision-making; and the benefits of having a palliative care summary.

Conclusion

Effective daytime and anticipatory care can positively influence OOH care. Interventions that aid patients in understanding cancer pain, communicating about pain, utilising analgesics effectively, and seeking appropriate and timely help may improve cancer pain management.     

Primary care access to computed tomography for chronic headache

Background

The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services.

Aim

To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care.

Design of study

Prospective observational analysis of GP referrals to an open access CT brain scanning service.

Setting

Primary care, and outpatient radiology and neurology departments.

Method

GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan.

Results

There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period.

Conclusion

An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.     

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.     

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

Background

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers

Aim

To explore factors that support partnership working between specialist and generalist palliative care providers.

Design

Systematic review.

Method

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

Results

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

Conclusion

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.     

Missed opportunities: mental disorder in children of parents with depression

Background

Emerging evidence suggests that early intervention and prevention programmes for mental health problems in the offspring of parents with depression are important. Such programmes are difficult to implement if children with psychiatric disorder are not identified and are not accessing services, even if their parents are known to primary care.

Aim

To investigate service use in children of parents who have recurrent depression, and factors that influence such contact.

Design and setting

A total of 333 families were recruited, mainly through primary health care, in which at least one parent had received treatment for recurrent depression and had a child aged 9–17 years.

Method

Psychiatric assessments of parents and children were completed using research diagnostic interviews. The service-use interview recorded current (in the 3 months prior to interview) and lifetime contact with health, educational, and social services due to concerns about the child’s emotions or behaviour.

Results

Only 37% of children who met criteria for psychiatric disorder were in contact with any service at the time of interview. A third, who were suicidal or self-harming and had a psychiatric disorder at that time, were not in contact with any service. Lack of parental worry predicted lower service use, with higher rates in children with comorbidity and suicidality.

Conclusion

Most children with a psychiatric disorder in this high-risk sample were not in contact with services. Improving ease of access to services, increasing parental and professional awareness that mental health problems can cluster in families, and improving links between adult and child services may help early detection and intervention strategies for the offspring of parents with depression.     

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

Background

Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.

Aim

To explore processes underpinning the implementation of CKD management in primary care.

Design and setting

Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.

Method

Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.

Results

A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.

Conclusion

Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.     

Influence of primary care practices on patients’ uptake of diabetic retinopathy screening: a qualitative case study

Background

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes in England by enabling prompt diagnosis of sight-threatening retinopathy. However, the rate of screening uptake between practices can vary from 55% to 95%. Existing research focuses on the impact of patient demographics but little is known about GP practice-related factors that can make a difference.

Aim

To identify factors contributing to high or low patient uptake of retinopathy screening.

Design and setting

Qualitative case-based study; nine purposively selected GP practices (deprived/affluent; high/low screening uptake) in three retinopathy screening programme areas.

Methods

Semi-structured interviews were conducted with patients, primary care professionals, and screeners. A comparative case-based analysis was carried out to identify factors related to high or low screening uptake.

Results

Eight possible factors that influenced uptake were identified. Five modifiable factors related to service and staff interactions: communication with screening services; contacting patients; integration of screening with other care; focus on the newly diagnosed; and perception of non-attenders. Three factors were non-modifiable challenges related to practice location: level of deprivation; diversity of ethnicities and languages; and transport and access. All practices adopted strategies to improve uptake, but the presence of two or more major barriers made it very hard for practices to achieve higher uptake levels.

Conclusions

A range of service-level opportunities to improve screening attendance were identified that are available to practices and screening teams. More research is needed into the complex interfaces of care that make up retinopathy screening.