Creating a shared vision of out of hours care: using rapid appraisal methods to create an interagency,community oriented,approach to service development.

OBJECTIVES--To undertake a district wide review of out of hours primary health care services and identify the views of users and providers about current arrangements and options for development. DESIGN--A range of qualitative and quantitative survey methods based on rapid appraisal methods, modified to apply to an inner city district. SETTING--Socially deprived, multiethnic district in south east London with a population of over 700,000. MAIN OUTCOME MEASURES--Strengths and weaknesses of current out of hours services and suggestions for developments. RESULTS--Widespread dissatisfaction with current arrangements was identified, with specific problems relating to access, availability, demand for services, and interagency communication. Several areas for development were identified, including the establishment of an out of hours cooperative, multiagency primary care emergency centres, and telephone advice-triage. Many of these are now being planned or piloted. CONCLUSIONS--Rapid appraisal provided a helpful method, enabling partnerships to be established between local agencies and users in relation to service development. The shared understanding and commitment to improving services that resulted is now having a major impact on out of hours care in the district.     

État des lieux des organisations de la prise en charge psychologique dans les réseaux et recommandations de la SFPO

In 2007, the SFPO (French Psycho-Oncological Society) created a Care Network Commission, which was to conduct a two-year survey regarding the organization of psychological management within 148 oncology and palliative care networks in France. The results demonstrate the need for trained psychologists. We here present some of the SFPO recommendations on this topic.     

Patients' assessment of out of hours care in general practice

A sample of 177 patients drawn from 13 north London practices were interviewed shortly after they had sought help from their practice outside normal surgery hours. Patients were asked to describe the process and outcome of their out of hours call, to comment on specific aspects of the consultation, and to access their overall satisfaction with the encounter.Parents seeking consultations for children were least satisfied with the consultation; those aged over 60 responded most positively. Visits from general practitioners were more acceptable than visits from deputising doctors for patients aged under 60, but for patients aged over 60 visits from general practitioners and deputising doctors were equally acceptable.Monitoring of patients'' views of out of hours consultations is feasible, and the findings of this study suggest that practices should regularly review the organisation of their out of hours care and discuss strategies for minimising conflict in out of hours calls—particularly those concerning children.     

Recognizing intimate partner violence in primary care: Western Cape, South Africa

Introduction

Interpersonal violence in South Africa is the second highest contributor to the burden of disease after HIV/AIDS and 62% is estimated to be from intimate partner violence (IPV). This study aimed to evaluate how women experiencing IPV present in primary care, how often IPV is recognized by health care practitioners and what other diagnoses are made.

Methods

At two urban and three rural community health centres, health practitioners were trained to screen all women for IPV over a period of up to 8 weeks. Medical records of 114 thus identified women were then examined and their reasons for encounter (RFE) and diagnoses over the previous 2-years were coded using the International Classification of Primary Care. Three focus group interviews were held with the practitioners and interviews with the facility managers to explore their experience of screening.

Results

IPV was previously recognized in 11 women (9.6%). Women presented with a variety of RFE that should raise the index of suspicion for IPV– headache, request for psychiatric medication, sleep disturbance, tiredness, assault, feeling anxious and depressed. Depression was the commonest diagnosis. Interviews identified key issues that prevented health practitioners from screening.

Conclusion

This study demonstrated that recognition of women with IPV is very low in South African primary care and adds useful new information on how women present to ambulatory health services. These findings offer key cues that can be used to improve selective case finding for IPV in resource-poor settings. Universal screening was not supported by this study.     

Impact of nurse practitioners on workload of general practitioners: randomised controlled trial

Objective To examine the impact on general practitioners'' workload of adding nurse practitioners to the general practice team.Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.Setting 34 general practices in a southern region of the Netherlands.Participants 48 general practitioners.Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.     

The role of deputizing agencies in the delivery of primary health care services.

When not available to their patients, family practitioners in large cities can "sign out" to deputizing agencies, which coordinate the activities of part-time physicians on call. The physicians making use of one such agency in Toronto appeared to be representative of family practitioners in the region. One thousand of their patients seen consecutively by one physician were asked a series of questions. The majority of the 811 evaluable patients were considered to have problems justifying an after-hours call, although 16% of the problems were of a trivial nature. However, almost half of the patients with trivial problems would have gone to the local emergency room, as would 85% of all the patients. Although virtually all (94%) of the visits with the elderly were justified, 34% of the patients in this age group said they probably or definitely would not have sought emergency room care if a physician had not been available. The use of deputizing agencies should reduce the overuse of emergency room facilities and provide optimal after-hours primary medical care.     

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients'' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.     

Confidential paediatric inquiry into neonatal deaths in Wessex, 1981 and 1982.

From 1 January 1981 to 31 December 1982, 66 256 births and 386 neonatal deaths were recorded in the Wessex Regional Health Authority, giving a neonatal mortality of 5.8/1000 live births. An experienced consultant paediatrician undertook a confidential inquiry into each death shortly after it had been reported. One hundred and forty four deaths (37%) were found to be due to lethal or severe malformations, an incidence of 2.2/1000 births. Of the 242 normally formed infants, 111 (46%) died within 24 hours of birth. Seventy seven (32%) weighed over 2500 g at birth. Factors operating before delivery accounted for 104 (43%) of the deaths of normally formed infants. The commonest factors were short gestation and low birth weight, and intrauterine hypoxia and birth injury. Factors after delivery accounted for 81 deaths (33%), the commonest being infections and sudden infant deaths. In the remaining 57 deaths (24%) it seemed that a combination of factors before and after birth had led to the death. Factors before birth thus played a part in two thirds of all deaths. Possible adverse factors in medical care were sought in 154 potentially viable babies and were identified in 38--that is, 10% of all neonatal deaths. Better provision and training of district staff in immediate care at birth would achieve more in lowering neonatal mortality in Wessex than the setting up of a regional unit specializing in advanced neonatal intensive care. Moreover, the greatest scope for improving the outcome of childbirth in Wessex would be offered if there were further advances in obstetric rather than neonatal care.     

Detecting mental disorders in primary care

Managing mental health problems of people around the world is a major challenge for health workers as well as for policy makers. It is a particular problem for low- and middle-income countries for many reasons, especially due to lack of recourses.A computer-assisted interview, the GMHAT/PC (Global Mental Health Assessment Tool - Primary Care) has been developed to assist general practitioners and other health professionals to make a quick, convenient, and comprehensive, standardised mental health assessment. It has proved to be a reliable and valid tool in various studies. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings more effectively. The article outlines the development and potential use of the GMHAT/PC.     

Preregistration house officers in eight English regions: survey of quality of training.

OBJECTIVE--To assess the quality of preregistration house officer training in eight English regions. DESIGN--Postal questionnaire. SETTING--Thames, East Anglian, Mersey, Northern, and Wessex regions. PARTICIPANTS--1670 preregistration house officers. MAIN OUTCOME MEASURES--Education, hours of work, workload, conditions of work, and attitudes to job and medicine as a career. RESULTS--Response rate was 69% (1146 replies). Most house officers had attended induction courses (1036/1129 (92%)); 74% (757/1024) found them satisfactory. The proportions who had never received adequate guidance on how to break bad news and how to control pain were 59% (670/1135) and 56% (634/1136) respectively. There was much variation between regions. Overall, 65% (736/1138) reported confidence in performing cardiopulmonary resuscitation. Most respondents (95% (1089/1142)) worked an on call rota, 3% (36) a partial shift, and 0.6% (seven) a full shift; 19% (202) were on duty for average weekly hours that exceeded the targets for 1 April 1993. House officers had a median of 20 patients under their care and clerked a median of 10 emergency cases, six routine cases, and two day cases a week. Over half (690/1128 (61%)) could not obtain hot food after 8 pm, 20% (223/1095) did not always have clean sheets available in their on call room, and 45% (462/1036) did not consider the protection of staff against violence to be adequate at their hospital. The most important problems with the preregistration year were inappropriate or non-medical tasks (ranked first by 360 respondents), hours of work (359), and pay for out of hours work (167). Overall 57% (646/1125) would encourage a friend to apply for their post, but only 24% (266/1112) would encourage a friend to take up medicine and 44% (494/1112) would discourage the idea. CONCLUSIONS--House officers'' training is deficient in important respects, with inappropriate tasks and heavy clinical workloads impeding the provision of proper education.     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis

ObjectivesTo assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services.DesignTime series analysis in walk-in centre sites with no-treatment control series in matched sites.SettingWalk-in centres and matched control towns without walk-in centres in England.Participants20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town.ResultsA reduction in consultations at emergency departments (–175 (95% confidence interval –387 to 36) consultations per department per month) and general practices (–19.8 (−53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services.ConclusionIt will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

What is already known on this topic

One of the objectives for NHS walk-in centres was to reduce demand on other NHS services, particularly general practitioners'' services and accident and emergency departmentsStudies of walk-in centres in North America have indicated that such centres do not reduce demand on other healthcare servicesStudies of minor injuries units in the United Kingdom (which have some similarities with walk-in centres) indicate that these units substitute mainly for consultations in accident and emergency departments

What this study adds

The data imply that walk-in centres may moderate the increasing demand on general practice and reduce the number of consultations in accident and emergency departmentsThe high level of background variability in consultation rates means that any impact of a walk-in centre is not statistically significantTo draw robust conclusions about the impact of walk-in centres on other health providers will require study of a large number of sites over an extended period of time     

Reported management of threatened miscarriage by general practitioners in Wessex.

Questionnaires were sent to all 1432 general practitioners in the Wessex region to obtain information about their current management of bleeding in early pregnancy. A total of 1290 (90%) returned completed questionnaires. These showed widely varying views about the prognostic importance of particular symptoms and physical signs and about elements of management. Although 96% of the respondents prescribed bed rest more or less routinely for heavy bleeding in early pregnancy, only 17% felt it was mandatory, and 32% admitted that they did not believe it affected the outcome. Of the 13% of respondents who prescribed progestogens for threatened miscarriage, most did so on the advice of their local obstetrician. Seventeen per cent of the doctors always admitted women with apparently complete miscarriages to hospital. Twenty nine per cent of the respondents never gave anti-D immunoglobulin to rhesus negative women after a complete miscarriage. Bleeding in early pregnancy is a common problem and more research is required to improve management, particularly the assessment of fetal viability.     

B.M.A. Deputizing Service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers'' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of “personal doctoring” was not threatened.     

Out of hours service in Denmark: evaluation five years after reform

Objective: Five years after its introduction, to evaluate the 1992 reform in the out of hours service in Denmark. Design: Comparison of data before and after reform. Data were collected from published reports, Danish national health statistics, and the Danish trade union for general practitioners. Setting: Denmark. Main outcome measures: Number of out of hours services; workload of general practitioners; cost of the service; patient satisfaction. Results: Five years after the reform, the percentage of telephone consultations had almost doubled, to 48%. Consultations in doctors’ surgeries were relatively unchanged, but home visits were much reduced, to 18%. The percentage of doctors who worked 5 hours or more out of hours per week dropped from about 70% to about 50%. Overall patient satisfaction in 1995 was high (72%). Conclusion: The organisation of the out of hours service, with a fully trained general practitioner in a telephone triage function, is working satisfactorily. Many calls that previously would have required home visits are now dealt with by telephone or through consultations. The out of hours workload for general practitioners has decreased considerably.

Key messages

• The out of hours reform in Denmark has resulted in an organisation with a fully trained general practitioner performing the telephone triage function
• Hours on call for general practitioners have decreased considerably
• Home visits have largely been replaced by telephone consultations
• Patient satisfaction has declined slightly

     

Provision of first contact care out of hours in four urban areas in England.

In a typical two week period in 1984 in three urban areas with general practitioner deputising services roughly 40% of first contact patient encounters out of hours were with hospital accident and emergency departments, and only a quarter were with general practitioner deputising services, although 47%, 64%, and 97% of general practitioners in the areas had permission to use such services. Roughly a third only of the encounters were with the practices themselves, and even fewer occurred overnight (11 pm-7 am). In a fourth urban area where 68% of general practitioners formed an out of hours cooperative rota a third of the encounters were with the accident and emergency department and half (more overnight) were with the rota. The presence of a woman principal in a practice and large partnerships of four principals or more were associated with an increased proportion of encounters with the practice itself. Undue prominence may have been given to the role of deputising services in out of hours care. Paradoxically, the use of general practitioner cooperatives may result in even less personal care being given by the patient''s own practice.