Redesigning primary care for the people who use it

Unveiling the results of the 3D trial for patients with multimorbidity in general practice

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by Chris Salibsury, Peter Bower, Stewart Mercer and Bruce Guthrie

There is good agreement about the sort of care that people with multimorbidity need. But can it be delivered in the busy setting of general practice, and does it improve outcomes? In this blog we discuss the results of the 3D trial, the largest study of an intervention for multimorbidity published to date.

Managing multimorbidity is a litmus test for modern health care systems. Patients with many long-term conditions face major challenges in managing their conditions and need significant support, which means that these patients are often associated with high costs.

Despite the complexity of caring for these patients, there is also significant agreement about what sort of care they need. Many authors have highlighted that patient-centred care is crucial, … Read more

Repeat prescriptions are expensive and time consuming – it’s time for an NHS rethink

 

Dr Rupert Payne
Centre for Academic Primary CareUniversity of Bristol
@DrRupertPayne

 

 

 

Dr Céline Miani
University of Bielefeld
@celine_miani

Over a billion NHS prescription medicines are issued by pharmacists in England every year – at a cost of over £9 billion. Many of these are prescribed by GPs to manage long-term health conditions, such as diabetes or cardiovascular disease.

The current “repeat prescription” system allows patients to request a further supply of medicines without the inconvenience of another doctor’s appointment.

The UK Department of Health advises that the frequency of repeat prescriptions should “balance patient convenience with clinical appropriateness, cost-effectiveness and patient safety”.

However, it does not recommend a specific time period. As a result, local health service commissioners have developed their own guidance, with many encouraging GPs to issue short-term supplies of repeat medications, typically 28 days in length. This is supported by … Read more

Collaborative action planning is key to person-centred healthcare but how can we make it happen?

 

by Cindy Mann
Senior Research Associate
Centre for Academic Primary Care
@Jcindymann


Person-centred healthcare
is accepted as desirable on moral grounds and because it potentially leads to better health outcomes, greater efficiency and less waste. It means both involvement of individuals in their healthcare and individualisation of care.

The NHS has been chasing the goal of person-centred care planning for several years and there are many good examples of innovation. The ‘House of Care’ describes what it might mean in practice for people with long-term conditions. At its heart is personalised care planning, taking account of patients’ expressed needs and priorities. The national new models of care programme, involving 50 vanguard sites, is also pursuing this goal and recently reported on lessons learnt. Many of the vanguards have invested in health coaching and communication skills training for clinicians.

I recently worked on a large research project, … Read more

How gut feeling guides clinician treatment decisions and why it’s not always enough

 

by Sophie Turnbull
PhD Student
Centre for Academic Primary Care

 

Clinician intuition and gut feelings are often talked about in health care but are largely mysterious. Clinicians describe just knowing that there was something wrong with a patient but not exactly how they came to that conclusion.

In a recent study we aimed to unpick how clinicians form their gut feelings, how they use them to influence treatment decisions, and whether their gut feeling was good at predicting whether a child with infectious cough would get sicker in the 30 days after seeing them.

Using gut feeling to predict outcome in children with infectious cough

Infectious cough in children is the most common problem managed by health services internationally.  Although the majority of children get better on their own, a small proportion end up hospital with a serious illness. Clinicians do not always find it easy to … Read more

Why the annual winter health crisis could be solved in homes, not hospitals

 

by Professor Richard Morris
Professor in Medical Statistics
Centre for Academic Primary Care

 

As winter continues, so does the usual soul searching about the state of the UK’s National Health Service (NHS). Images of ambulances backing up outside emergency departments and patients lying on trolleys in corridors haunt politicians and the public alike.

Demand on the NHS, which is always high, increases over the coldest of seasons, when threats to health are greatest. Generally, more than 20,000 extra deaths occur from December to March than in any other four-month period in England and Wales. That number varies considerably, however – from 17,460 in 2013-4 to 43,850 in 2014-5 (which was not even a particularly cold winter). And there has been no evidence of a decreasing trend since the early 1990s, despite the national flu immunisation programme.

The percentage increase in deaths seen each winter in England and Wales … Read more

Why doctors need to improve the way we discuss assisted dying

Paul Teed
PhD candidate
Centre for Academic Primary Care 
University of Bristol

Assisted dying can be a divisive and polarising subject. But there is one aspect on which most people probably agree – the need to improve the conversations people have about death.

At the moment, there is uncertainty in the UK regarding what people – especially health professionals – can and cannot say when the topic of assisted dying comes up. Conversation can become especially stilted when it turns to patients obtaining the medical documentation required for an assisted death abroad.

The situation requires clarification. Currently, if a doctor in the UK writes a specific report to help with an assisted death abroad (three organisations in Switzerland accept UK citizens), the General Medical Council (GMC) may view this as a “fitness to practice” issue.

However, if a doctor provides copies of medical records, even with the knowledge that … Read more

How we learned to love doing workshops

 

by Jessica Roy
Research Associate
Centre for Academic Primary Care
@DV_Bristol


The prospect of running a three-hour conference workshop can provoke anxiety even for the most seasoned conference-goer. Last month, I was a member of the IRIS+ research team, led by Dr Eszter Szilassy, that attended and presented a workshop at the Second European Conference of Domestic Violence in Porto, Portugal.

The conference brings together researchers, practitioners and policy makers from all corners of the globe to discuss, debate and exchange knowledge regarding domestic violence and abuse (DVA).

For context, the IRIS+ project is a training and intervention programme to support clinicians (GPs and nurses) to identify, document and refer female and male victims and perpetrators of DVA, as well as their children, to our dedicated specialist support service.

Before presenting, we had concerns that our workshop might not attract an audience, partly because we thought our … Read more

How do we teach clinicians to talk about the end of life?

By Dr Lucy Selman
Research Fellow (Qualitative Research in Randomised Trials)
Centre for Academic Primary Care
@Lucy_Selman

 

Image credit: Doctor and patient – Government of Alberta. Creative Commons License 2.0 (Non-commercial No Derivatives). Source: Flickr: https://www.flickr.com/photos/governmentofalberta/21221196734

In a systematic review published this month, we identified 153 communication skills training interventions for generalists in end of life care. In randomised controlled trials, training improved showing empathy and discussing emotions in simulated interactions (i.e. with actor patients) but evidence of effect on clinician behaviours during real patient interactions, and on patient-reported outcomes, was inconclusive.

The global increase in the proportion of older people and length of life means providing end of life care is now increasingly the responsibility of generalist as well as specialist palliative care providers. But many clinicians find communicating about end of life issues challenging: how do you best discuss imminent mortality, limited treatment options, what to … Read more

Safety-netting advice: my experience as an Academic Foundation Programme doctor

by Dr Peter Edwards
Research Associate/Academic Foundation Year 2 doctor
Centre for Academic Primary Care

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Patients can deteriorate rapidly.

I know this from working in both general practice and as a hospital doctor in A&E.

During the early stages of an illness it can be difficult for even the most experienced healthcare professionals to determine whether a patient has a minor self-limiting illness or is harbouring a more serious condition. In addition, growing problems such as antibiotic resistance and multimorbidity mean that sometimes even when a doctor makes a correct diagnosis, patients do not always get better with the first round of treatment and may require further medical help.

We cannot, and it is not clinically appropriate, to admit everyone to hospital to observe them until they feel 100% better.

That is why it is important that healthcare professionals provide patients with safety-netting advice. Safety-netting … Read more

Measuring outcomes in primary care

by Dr Mairead MurphyDr Mairead Murphy
Senior Research Associate
Centre for Academic Primary Care

With ninety percent of patient interaction with health services going through primary care, it’s not surprising that primary care clinicians and researchers try to figure out ways to improve primary care services. Interventions are many and varied, and result in important questions about their effectiveness. Do electronic consultations offer a good service to patients? If GPs introduce advice on healthy lifestyles into the consultation, does it make patients healthier? What about increasing the duration of GP appointments to ten minutes – does this improve outcomes for patients? Or ensuring that patients always see the same named doctor? Or painting the waiting room green?

Questions like these are normally answered by administration of a generic patient-reported questionnaire. By comparing the responses of groups of patients (say those with eight minute consultations and those with ten minute consultations), researchers can … Read more