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Health care systems are changing around the world; family doctors need to adapt and prepare for future challenges.
To consider the present status of family doctors, anticipated changes in health care systems, the challenges these will bring and possible solutions.
Collection of information
Collaborative enquiry amongst members of the International Federation for Primary Care Research Networks (IFPCRN). Six strategic questions were addressed by 37 contributors from 23 countries. Responses were collated and contributors invited to further comment on the interim report.
Present status: Despite wide variability, common problems relate to delivery systems, funding and policy, lack of evidence-based medical practice, education and research. Role of family doctors: There is wide variability in roles and often poor interaction with other caregivers. Anticipated changes: An expansion of the family physician model is anticipated, alongside shortages of family doctors in the face of increased health care needs, increased complexity of problems and the shift to ambulatory care. Advances in information technology may be useful. Anticipated challenges and proposed actions: Address quality issues. This requires audit and quality assurance, promoting adaptability, promoting group practices and teamwork, coordinating care, incorporating information technology and ensuring ethical relationships with industry. Improve education and continuing professional development: Improved education and continuing professional development are needed, as are measures to prevent burnout and retain the workforce. Develop a robust research enterprise: Research in primary care is needed to develop relevant guidelines. Improve support for family doctors: Providing excellent patient care is essential for improved status and support. Achieving this requires engagement with policy makers, academic institutions and the public.
While there is great variability across different countries, common themes relate to present status, anticipated changes in health systems and the responses needed from family medicine.
To evaluate a new service development whereby a nurse and a paramedic working in partnership attended non-urgent emergency calls.
The demand for emergency ambulance services both nationally (in the UK) and internationally has been steadily increasing. A large proportion of calls made to the emergency ambulance service are classified as non-urgent. An alternative response to these calls may release the standard ambulance service to attend more urgent calls. A pilot project was initiated in order to provide an alternative response to non-urgent emergency calls in an Ambulance Trust in England with support from the local Primary Care Trust. This alternative response comprised a district nurse or an emergency nurse practitioner dispatched with a paramedic to visit low-priority emergency calls. The pilot service was trialled during a 15-week period in 2003–2004.
This paper evaluates the cost effectiveness of the pilot service by examining both the resource use and the outcomes of the service.
It was found that introducing this service to the current provision would increase the overall cost to the ambulance services. However, a reduction in conveyance rate to the hospital was observed as people could be treated on-scene. A reduction in conveyance rate to the hospital would lead to reduced admissions to accident and emergency departments and subsequent hospitalization. This paper provides an indication that further development of this type of service has the potential to be cost effective, if the wider health care economy is considered, as the cost savings made in secondary care could more than balance the costs to the Ambulance Services in providing such a service.
Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project.
Aims and methods of study
The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre.
Development of the study
Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge.
Learning from the study
Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address.
To evaluate the antibiotic prescribing of prescriber-trained nurse practitioners in a primary care setting.
As of 1st May 2006, legislation was introduced extending the prescriptive powers of appropriately trained nurses and nurse practitioners to nearly equal that of fully registered doctors. Following this increase, we believe that it is important to ensure that these new powers are being used judiciously. In this paper, we focus on a particular aspect of prescribing: that of antibiotics in a primary care setting. We examine how the prescriber-trained nurse practitioners’ prescribing of antibiotics compares with the practice guidelines on prescribing.
An audit of all consultations for six months following 1st May 2006 by the three nurse practitioners trained to prescribe was conducted. Where an antibiotic was prescribed, the anonymous clinical detail was compared with the appropriate practice guideline. The antibiotic-prescribing habits of doctors were identified from a literature search using Medline, by using UK-wide data provided by the Prescriptions Pricing Authority and from the practice Primary Medical Services review.
The nurse practitioners were found to prescribe antibiotics in a total of 1296 out of 3211 consultations at an average monthly rate of 41 per 100 consultations. The most common antibiotics prescribed in descending order of frequency were as follows: amoxicillin; flucloxacillin; erythromycin; pencillin V; cefalexin and trimethoprim. Of the antibiotics prescribed during this period, 1065 were found to adhere to practice guidelines and 200 did not. A further 31 were deferred prescriptions. Off-guideline prescribing was accompanied by clear clinical indication as to the reason for the prescription identified in the medical record. Overall prescribing rates in this study of 80 per 100 consultations (including items other than antibiotics) are comparable with those published in the literature.
The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract.
This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract.
Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis.
The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients’ openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the individual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient’s attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer.
A CAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions.
The professional practice environment of hospital-based nurses has been the focus of considerable attention over the last few decades. More recently, attention has been paid to the community nursing environment, and this study considers the context of public health nursing in New Zealand.
The purpose of the study was to identify the organizational attributes that public health nurses consider important, and those that are considered less important, for professional practice and to rate the presence of these attributes within the public health nurses’ work environment.
In all, 167 public health nurses across New Zealand assessed the importance and presence of 48 organizational attributes in the nursing work environment using the Nursing Work Index-Revised (NWI-R). This instrument was developed from work with Magnet hospitals in the US and is designed to measure attributes of the professional nursing environment. Frequency distributions and difference scores were calculated using SPSS-PC.
Results showed that there was strong agreement that most NWI-R attributes were considered important for professional practice, the most highly endorsed relating to support from the organization, education/orientation and staffing. However, agreement that these attributes were actually present in the current work environment was much less strong. Participants also generated additional ideas for attributes considered important for public health nursing practice and these were categorized under four headings concerning specialty practice, resources, networking and education/research.
Primary health care service delivery in New Zealand is in an exploratory phase as primary health organizations determine new models of service delivery to reduce the incidence and impact of chronic disease. As organizations have restructured from predominantly primary care providers, the incorporation of a population approach to practice is welcomed but has provided some challenges for providers and funders alike as they reorient and extend practice parameters and determine the most effective methods of service delivery.
To describe and critically examine the underpinning assumptions of a new service delivered through a primary health organization to reduce the impact and burden of chronic disease with a focus on lifestyle risk factors, acting on obesity, nutrition, physical activity and smoking.
‘Heartbeat Tararua’ is a community-based lifestyle change programme focusing on the issues of obesity, nutrition, exercise and smoking and provides both clinical care for high-risk clients as well as operating a community-based prevention programme. The simplistic health education–behaviour change model was identified as problematic in the population approach and the high-risk service alone was unable to address all clients who expressed an interest. A revised population approach was sought that encompassed the existing community capacity and encouraged sustainable change in the community. Drawing from the public health evidence base a revised framework was recommended with a set of strategies based on social–psychological and ecological models with participatory and empowerment approaches. The work demonstrates a skilled practice team well able to reflect on practice, willing to seek advice and work towards establishing new models of primary health care service delivery.