British Journal of General Practice最新文献

Background: The communication of poor prognosis from secondary to primary care helps to ensure that patients with life-limiting illness receive appropriate coordinated care in line with their preferences. However, little is known about this information-sharing process.

Aim: To determine how poor prognosis is communicated from secondary care to primary care.

Design and setting: This was an international systematic review and narrative synthesis of studies published in English.

Method: Four electronic databases were searched from 1 January 2000 to 17 May 2021, supplemented by hand-searching of key journals. One-quarter of titles and abstracts were independently screened by a second reviewer. Two reviewers undertook data extraction and quality appraisal, independently using the Mixed Methods Appraisal Tool. Data were analysed using narrative synthesis. Reporting follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

Results: Searches identified 23 853 unique studies of which 30 met the inclusion criteria. Few studies had a focus on the interprofessional communication of poor prognosis. Information about prognosis was not commonly communicated from secondary to primary care and was more likely to occur if death was imminent. Lack of identification of poor prognosis by secondary care teams was a barrier. Facilitators included shared electronic records and direct clinician-clinician contact. GPs welcomed this information from secondary care and felt it was vital for continuity of care.

Conclusion: Although the communication of poor prognosis from secondary to primary care is highly valued it is rare and associated with cultural and systemic challenges. Further research is necessary to understand the information needs of GPs and to explore the challenges facing secondary care clinicians initiating this communication.

Background: Since 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services using a hybrid of remote, digital, and in-person care.

Aim: To examine how quality domains are addressed in contemporary UK general practice.

Design and setting: Multi-site, mostly qualitative longitudinal case study, placed in UK national policy context.

Method: Data were collected from longitudinal ethnographic case studies of 12 general practices (2021-2023), multi-stakeholder workshops, stakeholder interviews, patient surveys, official reports, and publicly accessible patient experience data. Data were coded thematically and analysed using multiple theories of quality.

Results: Quality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised.

Conclusion: Contemporary hybrid general practice features changes (digitalisation, physical distancing, extension of roles, and protocolisation) that have had the unintended effect of dehumanising, compromising, and fragmenting care. Policymakers and practices should urgently address the risks to patients and the traditional core values of general practice should be urgently addressed.

Background: People with long-term physical conditions are more likely to experience distress, depression or anxiety. Physical-mental comorbidity is associated with lower quality of life, poorer clinical outcomes, and increased mortality than physical conditions alone. South Asians (SAs) are the largest minority group in the UK, and more likely to have long-term conditions (LTCs) such as diabetes and heart disease.

Aim: To explore how men of SA origin with LTCs understand and experience emotional distress as well as the experiences of GPs supporting them.

Design and setting: UK qualitative study interviewing SA men with diabetes or coronary heart disease, and GPs working at practices with higher proportions of SAs.

Method: Online semi-structured interviews with SA men and GPs. Data were analysed via reflexive thematic analysis. Topic guides were modified iteratively as data collection and analysis progressed. An ethnically appropriate patient advisory group of SA men was involved in all stages of the research.

Results: Seventeen SA men with LTCs and 18 GPs were interviewed. Participants described contextualising distress including the interaction between having a LTC and distress, and the intersections of social determinants of distress including ethnicity, poverty and perceptions of prejudice. Participants understood distress as different to depression with the need to negotiate multiple identities as well as alternative paradigms of health.

Conclusion: This study highlights the influence of social determinants of distress in SA men with LTCs. It provides an insight into how primary care has the potential to address health inequalities by considering the intersection of these factors.

Background  Vulval lichen sclerosus (VLS) is a chronic inflammatory condition that is frequently misdiagnosed and under-recognised. To date, qualitative research focuses on lived experience of VLS, with women attributing diagnostic delay to poor interactions with health care professionals (HCPs) often due to lack of knowledge. In the UK, women with VLS are most likely to present to primary care.  Aim  To establish HCPs perspectives on identification, management and education of vulval skin disease, with a focus on VLS.  Design and Setting  A survey was distributed to HCPs working in primary care.  Method The survey was distributed via professional networks and at events. Analysis comprised of descriptive statistics, Spearman's rank correlations, and thematic analysis.  Results   Of 122 respondents, 53 were General Practitioners (GPs) and 59 were GP trainees. 37.7% of respondents had never participated in teaching nor learning on vulval skin disease. Confidence in the identification of vulval skin disease positively correlated with experience, exposure and female gender. The top identified barriers to diagnosis and treatment included lack of knowledge, embarrassment, and absence of VLS diagnostic criteria. Almost all participants (97.5%) felt VLS diagnostic criteria would be helpful in clinical practice.  Conclusion   This study provides insight into the barriers to diagnosing and treating VLS in primary care. HCPs recognise deficiencies in training, referral pathways and lack of tools to support VLS diagnosis. Training should include skills to address stigma and embarrassment. This study highlights the importance of developing interventions to overcome barriers, expediting diagnosis and treatment, such as reproducible diagnostic criteria.

Background: General Practice faces pressures due to increased demand and a shortage of GPs. Paramedics in General Practice (PGPs), increasingly contribute to managing minor illnesses, conducting home visits, and providing urgent consultations.

Aim: Explore the impact of paramedic-consultations on patient-reported experience, safe management and NHS costs.

Design & setting: Prospective cohort study comparing PGP with GP consultations at 34 GP sites in England.

Methods: Eligible participants had a consultation with a PGP (25 PGP sites) or GP (9 non-PGP sites) between May 2022 and February 2023. Questionnaires were provided after the initial consultation and 30 days later. Questionnaires assessed patient experience, outcomes and perceived safety (PCOQ and PREOS-PC), quality of life (EQ-5D-5L) and health care use.

Results: Of 715 participants recruited, 489 completed the 30-day questionnaire. We found no evidence that PGP-consultations resulted in greater improvement/deterioration in patient-reported health and wellbeing; confidence in health provision; health knowledge; or confidence in the health plan over the 30-day period. However, the PGP group reported lower confidence in health provision, poorer perceptions of practice engagement in safety promotion and more communication problems with staff immediately after the initial consultation. Patients receiving PGP-consultations reported fewer GP appointments during the 30-day period, however savings to the NHS were offset by higher use of other healthcare professionals.

Conclusion: Well-designed training and supervision are needed to ensure PGPs have the right knowledge and can clearly convey health care plans to patients. While PGPs may reduce GP workload pressure, they do not necessarily reduce NHS costs.