How to provide for the primary health care needs of homeless people: what do homeless people in Leicester think?

The best means of improving access to primary health care for homeless people remains controversial, but the debate may be informed by the opinions of homeless people. A questionnaire asked users of a homeless drop-in centre to choose between the options of facilitated access to mainstream primary health care or special provision for homeless people. While both models of care were endorsed, 84% of homeless people preferred a special homeless service.     

Specialist outreach clinics in general practice: what do they offer?

BACKGROUND: Specialist outreach clinics in general practice, in which hospital-based specialists hold outpatient clinics in general practitioners' (GPs) surgeries, are one example of a shift in services from secondary to primary care. AIM: To describe specialist outreach clinics held in fundholding general practices in two specialties from the perspective of patients, GPs, and consultants, and to estimate the comparative costs of these outreach clinics and equivalent hospital outpatient clinics. METHOD: Data were collected from single outreach sessions in fundholding practices and single outpatient clinics held by three dermatologists and three orthopaedic surgeons. Patients attending the outreach and outpatient clinics, GPs from practices in which the outreach clinics were held, and the consultants all completed questionnaires. Managers in general practice and hospital finance departments supplied data for the estimation of costs. RESULTS: Initial patient questionnaires were completed by 83 (86%) outreach patients and 81 (75%) outpatients. The specialist outreach clinics sampled provided few opportunities for increased interaction between specialists and GPs. Specialists were concerned about the travelling time resulting from their involvement in outreach clinics. Waiting times for first appointments were shorter in some outreach clinics than in outpatient clinics. However, patients were less concerned about the location of their consultation with the specialist than they were about the interpersonal aspects of the consultation. There was some evidence of a difference in casemix between the dermatology patients seen at outreach and those seen at outpatient clinics, which confounded the comparison of total costs associated with the two types of clinic. However, when treatment and overhead costs were excluded, the marginal cost per patient was greater in outreach clinics than in hospital clinics for both specialties studied. CONCLUSION: The study suggests that a cautious approach should be taken to further development of outreach clinics in the two specialties studied because the benefits of outreach clinics to patients, GPs and consultants may be modest, and their higher cost means that they are unlikely to be cost-effective.     

Priorities for research on mental health in primary care settings

A Delphi study was conducted with a multi-disciplinary group of experts attending a conference on mental illness in primary care settings. Respondents' priorities for research which could maximize benefits for service developments in this field were elicited by asking them to distribute hypothetical annual research budgets among (a) 6 mental health priority areas, and (b) 7 subjects 'needing' investigation within the primary care priority area. The respondents' three top-ranked priority areas for research were: (1) primary care; (2) the elderly mentally ill; and (3) chronically disabling mental illness. Their three top-ranked subjects for investigation within the primary care priority area were: (1) the effectiveness of treatment measures; (2) the problems of mental health presenting to primary care services; and (3) the training requirements for family doctors in psychiatric skills. The results are discussed with reference to the method used and to the economic concepts of programme budgeting and marginal analysis.     

Implementing health promotion in health care settings: conceptual coherence and policy support.

This article examines the level and conditions of development of the concept of "health promoting hospital (HPH)", in France and in Europe. Part of the literature on HPH was reviewed, looking at the kind of partnerships implemented within the HPH projects, and at the organisational strategies adopted by hospitals to be health promoting. The literature review is followed by an overview of the priorities defined by health policies in Europe. This research shows that there is still a lack of guidelines on how to put the health promotion concept into practice in health care settings. Moreover, it stresses that further research is needed in order to better define which personal skills ought to be developed through health education in health care settings, and how the development of such skills may be articulated to other priorities in health care settings.     

Summarizing recommendations to eliminate weight stigma in prenatal health care settings: A scoping review

ObjectiveAs the prevalence of obesity increases, more women are at risk of potentially experiencing weight stigma in prenatal health care settings. The objective of this scoping review was to summarize the primary literature assessing potential causes of weight stigma in prenatal health care settings and synthesize recommendations for health care providers to improve clinical practice.MethodsA search strategy was developed combining the terms pregnancy, weight stigma, obesity, and prenatal care. A systematic search was completed in the following databases: Medline, EMBASE, PsycInfo, CINAHL, Opengrey, and Proquest.ResultsEighteen resources were included in this review, of which 17 were qualitative, and one was a mixed-methods study design. Weight stigma occurred in prenatal health care settings when providers: avoided weight-related discussions, assumed lifestyle behaviors, and had poor communication when discussing risks associated with obesity. Recommendations to prevent weight stigma included: offering sensitivity training to discuss obesity during pregnancy, implementing a patient-centred approach, including evaluating individual health behaviors, and providing educational resources to patients explaining potential risks and referrals.ConclusionThis review summarizes recommendations to eliminate weight stigma in prenatal health care settings.Practice implicationsThese recommendations can be implemented in clinical practice and can improve the delivery of prenatal care.     

Telling the truth: what do general practitioners say to patients with dementia or terminal cancer?

A questionnaire was sent to all general practitioners (GPs) in Cambridgeshire asking them about their practice in telling patients with dementia or terminal cancer their diagnosis. Although the majority of GPs would always or often tell patients of a diagnosis of terminal cancer, this was not the case in dementia; uncertainty of diagnosis was cited as the most important factor in not giving the diagnosis. The implications of these findings are discussed in the light of the GP's role in dementia and the development of new anti-Alzheimer's drugs.     

Desire for autonomy in health care decisions: A general population survey

Objective

To examine factors associated with desire for autonomy in health care decisions in the general population.

Methods

Mailed survey of 2348 residents of Geneva, Switzerland. Participants answered questions on a scale measuring their desire for autonomy in health care decisions. The scale was scored between 0 (lowest desire for autonomy) and 100 (highest desire for autonomy).

Results

On average the respondents favoured shared or active involvement in medical decisions (mean score 62.0, SD 20.9), but attitudes varied considerably. In the multivariate model, factors associated with a higher desire for autonomy included female gender, younger age, higher education, living alone, reporting an excellent global health and - a new observation compared to previous studies - having made several medical decisions in the past 6 months.

Conclusions

The attitudes of the general public appear to be consistent with the model of shared decision making. However, people vary considerably in their desire for autonomy.

Practice implications

An explicit assessment of each individual's desire for autonomy may improve the decision-making process. Such an assessment should be repeated regularly, as familiarity with medical decisions may increase the desire for autonomy.     

Outcome measures for primary health care: what are the research priorities?

A Delphi technique was used to ask general practitioners for their opinions as to which clinical problems and types of measure they thought most appropriate for the development of outcome measures for use in primary health care. The study comprised two rounds of postal questionnaires, targeted at general practitioners in academic departments throughout the United Kingdom and at trainers in the northern region, with the second questionnaire feeding back opinions from the first. Ninety eight participants suggested one or more areas in which outcome measures could be developed, giving a total of 451 suggestions. Consensus produced in the second round indicated that three clinical conditions were preferred for the development of outcome measures: asthma, diabetes and hypertension. Six categories of outcome measures were developed from the responses given in the first round--level of function, level of clinical control, incidence of complications, iatrogenic problems, patient understanding of a condition, and quality of life. Participants gave these measures different levels of importance according to the clinical problem in question. This Delphi study of doctors' opinions is a first step in the development process of appropriate, practicable measures of outcome for use in primary care and has achieved a degree of consensus among general practitioners.     

Malpractice in pathology: what to do when you are sued

A malpractice suit arises when a patient brings legal charges against a physician for suffering that the patient claims to have endured because the physician failed to provide appropriate care. Suffering usually encompasses a measure of misdiagnosis and of rude treatment of the patient by medical staff. Polite treatment of all patients by all laboratory staff will prevent some disputes from ever forming, thus preventing some charges of malpractice. Even if a patient is treated rudely, that rudeness alone is insufficient to justify a charge of malpractice. Attorneys must follow legal guidelines to determine whether the physician's actions caused actual damage. As soon as a physician is served notice of a lawsuit, the physician must notify the office that insures him or her against claims of malpractice (eg, the office of risk management or the physician's malpractice insurance carrier). Being sued creates an overwhelming urge to talk about the case, but a physician who has been sued must not talk to anyone about the lawsuit or the case involved. Conversations about the lawsuit may only safely be had with the attorney who will defend the physician against the charge of malpractice. Despite any frustrations with the legal system, the physician must work with and even trust the attorney handling the defense. It is possible to overcome a charge of malpractice, but not if the physician creates an indefensible situation by committing fraud. Examples of fraud are changing the medical record or destroying the pertinent microscope slide.     

Access to health care prior to suicide: findings from a psychological autopsy study.

Previous research has suggested that progress towards suicide reduction targets may be achieved by improving the ability of general practitioners to recognise and treat mental illness. Using data from a study of suicide completers who were not in contact with specialist mental health services, we found that the rate of detection and treatment of mental health problems in primary care was high. The major barrier to receipt of care for mental health problems prior to suicide was non-consultation. The study also shows that detection and management in primary care does not necessarily result in prevention of suicide. Implications for public education, access to primary care services and the potential for suicide prevention are considered.     

Graduate education in clinical psychology for the twenty-first century: educating psychological health care providers

This comment focuses on a topic that is implied but not explicated in C.R. Snyder and T.R. Elliott's article (this issue, PP. 1033-1054): The biopsychosocial model. I begin by discussing the status of health care, taking up in turn its tremendous problems and the negative effects of a system built on mind-body dualism. I argue for a transformation of the biomedical system to a biopsychosocial system. I then discuss the opportunities for psychology and the implications for training.