British Journal of General Practice最新文献

Background: Post-inpatient discharge is a risky time for older patients, especially those with polypharmacy and multimorbidity. General practice care at this time, including the processes for managing hospital discharge summaries, lacks standardisation and is of variable quality. Understanding these processes will support the design of interventions and guidance to improve general practice management of the post-discharge period.

Aim: To understand and visualise how ongoing care for older people after discharge from hospital is organised in general practice, including the processes for managing discharge summaries.

Design and setting: Rapid ethnography study in 10 general practices in the West Midlands, England.

Method: We mapped the practices' systems of post-discharge care. Data sources included informal conversations with staff, practice policies, and direct observations of discharge summary handling. Fieldnotes and quotes were subject to an interpretivist framework analysis. A systems modelling technique (the Functional Resonance Analysis Method) was used to present visual representations of the professional roles working in these complex systems.

Results: Three basic typographies of system emerged based on professional roles: GP-led, pharmacist-led, and administrative-led. We report on three themes that weave around the Functional Resonance Analysis Method process maps: comfort with demands of administrative role; general practice team dynamics; and interaction with patients.

Conclusion: General practice systems for inpatient discharge summary processing are complex and varied. New roles in general practices are being used extensively, often requiring significant input in supervision by GPs. Our findings highlight safety features of different systems and should help practices understand the advantages and limitations of models they work within.

Background: A growing literature examines the way two changes in primary care - the shift towards remote working and the diversification of practice teams to incorporate, for instance, physician associates and paramedics - affect patient care within the practice. However, little is known about the effect of these changes on community nurses.

Aim: To explore community nurses' experiences of delivering palliative care in the context of GPs' new ways of working.

Design and setting: Qualitative study using focus groups in the UK.

Method: Focus groups were conducted on Zoom with community nurses. Data were analysed thematically using constant comparison.

Results: Community nurses described extending their roles in palliative care. Alongside pride and satisfaction about this, participants raised several areas of concern and dissatisfaction, some of which they associated with changes in GPs' ways of working. Two reasons for dissatisfaction concerned remote working. First, remote communication with colleagues was seen as creating obstacles to nurses' everyday collaboration with GPs, damaging important working relationships. Second, nurses increased their workload by taking the lead in person-centred care where they saw remote provision by GPs as unsatisfactory. Where workforce diversification led to delegating home visits to paramedics or nurse practitioners, community nurses described feeling a lack of the 'GP back-up' that many identified as essential for community palliative care.

Conclusion: When considering and evaluating interventions that change the way GPs work, policymakers and commissioners should look not only at consequences that affect primary care teams, but also at the effects across the complex ecosystem within which these teams operate.

Background: In England online services in general practice encompass a range of provision from ordering repeat medication to having a consultation. Some groups of individuals may find accessing and/or using such services difficult and may require 'digital facilitation', that is the range of processes, procedures, and personnel which seeks to support NHS patients in their uptake and use of online services.

Aim: To gain insight, from the perspective of general practice staff and patients/carers, into how and why digital facilitation might lead to benefits, and the key processes involved in supporting patients to use online services.

Design and setting: Eight general practices across England with varied geographical and sociodemographic characteristics were included in the study.

Method: This was a focused ethnographic case study of observations and interviews (N = 69).

Results: Typically, digital facilitation was delivered in an ad hoc fashion to individual patients. Online services were delivered via multiple systems each working differently and creating a need for support so that patients could access them. Younger practice staff were expected to deliver support on account of their age, despite there being no evidence of age-related training and experience. It was understood by practice staff that patients with challenging personal circumstances may require specific support to access online services.

Conclusion: At present patient use of online services is supported by digital facilitation that is primarily delivered by reception staff. Supporting patients to use online services requires review of how many services are provided and what for, and consideration for the time and effort needed to support patients to use them.

Background: An increasing number of pregnant women now take antidepressants. Many pregnant women experience decisional conflict when deciding whether to take antidepressants, but little is known about the attitudes and experiences that influence these decisions.

Aim: To explore the attitudes and experiences influencing women's decisions about antenatal antidepressant use.

Design and setting: A qualitative study using in-depth interviews with a sample of UK women who experienced antenatal depression or took antidepressants antenatally within the preceding 3 years.

Method: Recruitment adverts were placed by a perinatal mental health charity and on parenting forums and social media platforms, resulting in a convenience sample. Interview data were coded and analysed with thematic analysis using QSR NVivo.

Results: Twenty-two women were interviewed; one-half had taken antidepressants during pregnancy. Most women had concerns about adverse effects and viewed antidepressants as adjunctive to non-pharmacological treatments, which were reported as difficult to access. Some women reported that professional advice was insufficiently detailed. Women described the need to cope with their symptoms, their baby, and existing responsibilities, and related their decisions to their perceived ability to cope. This perception was influenced by physical and emotional challenges relating to pregnancy. Women's decisions were influenced by their previous experiences and by the perceived societal expectations placed on pregnant women.

Conclusion: Decision making is a complex and dynamic process, personal to each woman's circumstances. Perceived ability to cope is an important factor in decision making. Detailed information should be offered to women for support with decision making in relation to antenatal medication use.

Background: Faecal immunochemical testing (FIT) is now core to the management of patients presenting in primary care with symptoms of possible colorectal cancer. Patients with a positive FIT (≥10 μg haemoglobin [Hb]/g faeces) qualify for an urgent suspected cancer referral. FIT-negative patients are typically managed in primary care or referred through routine pathways.

Aim: To examine practitioners' experiences of delivering symptomatic FIT, identifying perceived benefits, disbenefits, and implementation issues, to inform potential future service improvements.

Design and setting: A qualitative interview study with primary and secondary care health professionals involved in delivering symptomatic FIT pathways from across the UK.

Method: Thirty semi-structured interviews were conducted with professionals from a range of specialties. An iterative topic guide informed interviews while allowing freedom to explore novel lines of enquiry. Pseudo-anonymised transcripts were coded, and themes were identified and developed.

Results: Symptomatic FIT was seen to be beneficial for increasing confidence in clinical decision making and enriching the pool of patients being definitively investigated for colorectal neoplasia. There were varying views on the impact of symptomatic FIT on workload with the burden of additional workload generally seen to impact primary care. Concerns about current practice included overuse of FIT, burden of investigations in patients with false-positive results, and diagnostic delays for both cancer and benign disease. Uncertainties existed around management of patients with rectal bleeding, appropriate strategies for safety netting, and the value of repeat FIT.

Conclusion: Symptomatic FIT is largely seen as beneficial; however, health professionals would welcome further evidence and guidance around optimal application.