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Tayside's Primary Care Research and Development Network (TayRen) was awarded £140K per annum for 4 years from 1998 by the Scottish Office Department of Health. The operating model of TayRen is described and the outcomes highlighted. A multiprofessional, multidisciplinary, methodologically rigorous and locally responsive approach has contributed to the outcomes achieved. The network has enabled practitioners to gain research experience by working with more experienced colleagues. The research culture of Tayside has matured since the formation of TayRen as evidenced by the increased number of research practices (six), training fellowships (three), registration for higher degrees (18), grants (£3.9m) and publications (96). In conclusion, TayRen has increased research activity in primary care in Tayside.
The objective of this paper is to describe variations in the different models of out of hours general medical services and identify explanations for variation and the possible influence on patient satisfaction and service costs. A cross-sectional survey of all models of out of hours care was undertaken, including co-operatives, deputizing services, practice rotas and rural general practitioners doing their own cover. Fifteen sites were chosen representing 10 models of care, for more detailed case study; 65 semistructured interviews with key informants were conducted within the case study sites. A postal patient satisfaction questionnaire and an economic analysis were also carried out. Out of hours organizations have developed in response to a complex mix of the population served, geography, resources available and political expediency, leading to considerable structural heterogeneity, even within co-operatives. There was little evidence of formal integration with other services. Only the largest co-operatives showed any evidence of utilizing guidelines/protocols or of providing formal staff training. There were clear differences in the structure of out of hours care in urban and rural areas. Increasing the use of centralized call handling and triage will not address the needs of rural GPs, who would still be required to be available for work. Neither patient satisfaction nor costs varied bymodel of service provision. The English out of hours reviewhas outlined an integrated model of service provision with consistent standards within an accountability framework. It would appear that only the largest organizations will be in a position to address these standards and that they are likely to be inappropriate to the needs of GPs in rural areas.
The Mant Report supports the need to involve primary care practitioners and their patients in research and development. This paper questions why this key report, that recognized the need for involvement of health care staff in R&D, did not identify the need for practitioner research methods in community practice. Next, it explores what is meant by practitioner-centred research and locates action research within this context. Drawing on ‘critical realism’ and ‘subtle realism’, the arguments for the use of action research in community research and development are explored. Caution is given to adopting extreme perspectives and, in preference to ‘practitioner-centred research’, practice-centred research is advocated. In conclusion, the paper suggests that the world of R&D is changing and that the time is right for influencing the uptake of alternative methods. It is suggested, given that 90% of contacts between the population and the NHS take place in primary care, it is vitally important that community-based practitioners are well versed with these arguments in order to move forward the debate and bring it closer to a vision of research that places practitioners more centrally in the process of research.
As an alternative to the national contract with general practitioners (GPs), Personal Medical Services (PMS) is a way of contracting with GPs for providing primary care, intended to enable individual contracts with practices which are appropriate to the specific needs of their populations. The national plan for the NHS (2000) strongly supports the extension of PMS as a means of improving the quality of primary care. This paper reports two small pilots which found PMS a useful mechanism for achieving desired changes within the practices. In one case, the GPs are now employed by the local community trust and the primary health care team has been expanded, with some clinical functions redistributed among the team. In the other, the primary health care teams of two practices have developed a tool for assessing the health and needs of older people during a home visit. Participants in both pilots expressed satisfaction with the results, although there were some dissenting voices. In both cases, the pilots were unable to demonstrate in detail any improvements in patient care or to quantify the work-load implications of the changes. Perhaps because of their ‘pilot’ status, the initiatives tended to be inward looking, and opportunities for learning across the local health economy have been missed. PMS' value as a driver for improving the quality of primary care is not demonstrated by these two examples.
This study attempted to elucidate the meaning of hope as it occurred in the lived experience of seven homeless people residing in a cold weather shelter and to identify strategies that are used to maintain hope. It adopted a hermeneutic, phenomenological method and produced an emerging theory comprised of five key themes. These were: expectancy with hope experienced as future imagined reality, a way out of present difficulties and concretely linked to having one's own home; connectedness perceived as a meaningful relationship between self and others (family, friends and the shelter) which sustained hope; view from the street experienced as a dichotomy between hope/joy and hopelessness/despair; emotionalism expressed as a barrage of varied and often conflicting emotional states which either strengthened or depleted hope and brokenness described as a feeling of being worn down and drained of energy due to the constant struggle for survival in harsh conditions on the street, which weakened hope. The study provided a clearer understanding of the meaning of hope from a homeless person's point of view. At the end it ponders the possible implications for primary health care nursing.
Current UK health policy guidance locates primary care at the frontiers of health care modernization. New organizational structures have resulted in general practitioner (GP) practices being brought together in Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) each serving a much larger population group than the traditional GP practice. These changes have been accompanied with a need to explore new ways of working and thinking. This paper draws upon the experiences of nurses and GPs participating in an evaluation of workforce planning issues in primary health care. It explores how practitioners working in PCGs across one geographical area were able to gain a better understanding of what these changes, to both the structure and process of practice, might involve. During this developmental process the respondents used ‘the family’ metaphor, as a form of ‘shorthand’ to orientate themselves to the new responsibilities, challenges and opportunities presented by these changes to primary health care. It was in the use of terms and constructs that were familiar to their ‘everyday life’ experiences that made taking the first tentative steps in the change process easier. This paper suggests that using metaphors may be a powerful tool for policy makers, practitioners,managers and for researchers as they seek to communicate a plan for change and in understanding what these changes might mean.
In England & Wales at least 140 000 people present at hospital annually following an episode of deliberate self-harm (DSH), and 12% to 16% make a repeat attempt. The time of greatest risk of repetition is within three months of an attempt. Around 50% of these patients visit their GP in the four to eight weeks after an episode of DSH. Guidelines for the aftercare of patients who have self-harmed in general practice may reduce repetition rates and could possibly have an impact on suicide rates. The aim of this study was to develop a clinical practice guideline for the aftercare of DSH patients in general practice. A modified Delphi technique was used with a consensus group consisting of GPs with an interest in mental health, psychiatrists, a psychologist, a specialist nurse, a voluntary organization and patients with a history of self-harm. The template for the guidelines was based on ICD-10 PHC. Consensus was reached on all points after two rounds of the Delphi and the guidelines were formatted to facilitate their use in the GP consultation. There is a difficulty developing guidelines for common problems where the evidence base is weak. The use of formal consensus methods can be employed but it must be acknowledged that the validity of the resulting guideline is related to the composition of the consensus group, the identification and analysis of any relevant evidence and the method of guideline dissemination. The guidelines are being evaluated in a randomized controlled trial of a general practice based intervention to reduce repeat deliberate self-harm.
This paper aims to address three broad themes. An outline of the current UK primary/community health care research and development (R&D) agenda is presented and it is argued that in addressing this agenda greater diversity of research designs and methods to generate knowledge for policy and practice is needed. It is proposed that philosophical and disciplinary entrenchment, particularly within nursing, has led to over preoccupation with arguments about the epistemological basis of research approaches and methods as an end in itself and the research priorities and questions for health and health care that should drive such debates are often side lined or altogether ignored. The remainder of the paper addresses Meyer's proposition for the need for more participative practitioner-centred research within the context of community/primary health care. It is argued that while action research and other participative research methods have much to offer we need to understand and use the full range of research approaches and methods at our disposal, and where appropriate, develop new ones if we are to tackle the research priorities relevant to a large and diverse community/primary care R&D agenda.
Motor neurone disease (MND) is a devastating neurological terminal condition with no cure. Care is the only option, which sharpens the need for its examination and clarification. This paper reports on a hermeneutic study which addressed the question, ‘What are the lay and professional values of care in the context of motor neurone disease and is there a difference between them which affects care delivery and receipt?’ The study discovered three ways of caring, with most alignment between the two lay groups. The professional carer stance is predominantly functional and illustrates detachment from the experience of living with illness whereas the recipients' needs are holistic. These two value structures, the mechanistic and the hermeneutic, are in tension. To redress this imbalance, support for a dispositional shift in professional values to be more client focused is advocated.
A number of inquiries over the last 20 years have found London's primary care to be deficient when compared with the rest of the country, notwithstanding several development programmes aimed at addressing this inequity. Personal medical services (PMS) pilots were introduced in 1998 to replace the national contract for general practitioners and were intended to offer planners and providers of primary care with more flexibility in meeting local health needs. PMS pilots have proved particularly popular in London. This paper describes the results of a review of 13 first-wave PMS pilots in London. The pilots have resulted in new and flexible primary care organizations, more resources for the primary care workforce and greater access to services for deprived or underserved populations. However, little evidence was found to suggest that PMS pilots impacted greatly on service quality. Personal medical services pilots involve the development of local contracts, although contract management processes remain underdeveloped. Nevertheless, personal medical services pilots may prove successful in addressing some of the relative deficiencies in London's primary care and offer a powerful new tool to the commissioners of primary care to meet the diverse needs of Londoners.
Eating disorders are amongst the most commonly encountered psychiatric disorders experienced by young women. Binge eating disorder (BED) has received some support as a distinct pathology, but is hard to disentangle from other kinds of behaviours. This qualitative study explored awareness and knowledge of BED amongst a group of 18 inner-city general practitioners in NW England. Thematic coding of their accounts suggested a dichotomous tension. (1) Subjects were largely unaware of the existence of BED, and found it difficult to conceptualize its diagnosis and management in primary care. (2) Subjects framed BED as a ‘disorder’ that was firmly within the sphere of patients' personal responsibility, and recognized that psychological distress would be an important causal factor in its aetiology. Subjects were reluctant to consider BED as a diagnosis for obese patients because of the absence of services for onward referral, and because of uncertainties about effective treatment.
Partnership figures prominently in the rhetoric of contemporary health care. The notion of an ‘active’, ‘informed’ patient in partnership with health care providers has permeated practice and policy globally. Consequently, understandings of partnership have colonized the social space that exists between health care providers and health care recipients. Drawing on Foucault's notion of discourse, this paper explores partnership as a discursive event and interrogates the way understandings about partnership construct how partnership is enacted, including the subject positions of health care professional and patient, which in turn construct understandings about partnership. The paper argues that partnership is more than simply participating in health care. It involves questioning who is offering whom what, and how. The discussion aims to trouble and unsettle taken for granted assumptions about partnership to allow for the possibility that partners can position themselves in the social space that is the site of the partnership in a way that enables the type of professional relationship and outcomes to be negotiated by both partners.
Objective: The care of patients with chronic diseases such as rheumatoid arthritis is increasingly shared between primary health care and hospital specialist teams. Studies that have informed guidelines for the shared care of patients with rheumatoid arthritis have not included patients' perceptions and preferences. The objective of this study was to explore the experiences and views of patients with rheumatoid arthritis concerning the clinical care they had received from general practitioners (GPs) and specialist hospital doctors.
Design: Semi-structured interviews analysed using grounded theory techniques.
Setting and Participants: A purposeful sample of twelve people receiving clinical care from specialist rheumatologists and GPs. All participants had received a diagnosis of rheumatoid arthritis at least two years previously.
Results: Most participants valued regular review by rheumatologists highly, and looked to them for help with all aspects of their arthritis care. They felt that specialists had greater knowledge concerning disease management than GPs, but both groups of doctors were similarly empathic. The GPs' role was perceived to be important mainly in early diagnosis and first referral to the hospital specialist but less so in the provision of continuing care or help with psychosocial issues. Participants valued the accessibility of GP services. Advice from any source about aids and welfare benefits was often haphazard.
Conclusions: People with rheumatoid arthritis prefer to have regular contact with a rheumatologist rather than obtaining care for their arthritis mainly from their GP. This has implications for the move from secondary to primary care.