To evaluate heuristics (rules of thumb) for recognition of undetected vision loss in older patients in primary care.

Vision loss is associated with ageing, and its prevalence is increasing. Visual impairment has a broad impact on health, functioning and well-being. Unrecognised vision loss remains common, and screening interventions have yet to reduce its prevalence. An alternative approach is to enhance practitioners’ skills in recognising undetected vision loss, by having a more detailed picture of those who are likely not to act on vision changes, report symptoms or have eye tests. This paper describes a qualitative technology development study to evaluate heuristics for recognition of undetected vision loss in older patients in primary care.

Using a previous modelling study, two heuristics in the form of mnemonics were developed to aid pattern recognition and allow general practitioners to identify potential cases of unreported vision loss. These heuristics were then analysed with experts.

It was concluded that their implementation in modern general practice was unsuitable and an alternative solution should be sort.

The purpose of this evaluation was to obtain views from general practitioners (GPs) who piloted the electronic risk assessment tools (eRATs) for suspected lung or colorectal cancer. We wanted to find out whether GPs were able to integrate these tools into their everyday practice. We were also keen to identify facilitators and barriers to their more widespread use.

Cancer remains one of UK’s biggest health problems, in terms of morbidity and mortality. Comparative European data show that five-year survival figures for many cancers are lower in the United Kingdom than in comparable European countries. eRATs are intended to aid recognition of symptoms of lung and colorectal cancers in patients aged 40 years and over.

This was a qualitative study; telephone interviews were conducted with 23 GPs who piloted the eRATs. A systematic qualitative analysis was applied to the data. The normalisation process model was used after data collection. This theory-driven conceptual framework was used to examine the operationalisation of this intervention in Primary Care.

Electronic decision-support tools appear to be useful additions to the resources available to GPs in order to assist them with recognizing potential cancer symptoms. However, the tools need to be refined in order to integrate them into GP practice. The tools raised GPs’ awareness about cancer because of the prompt facility of the software, although this also raised the potential of ‘prompt fatigue’. GPs constantly receive alerts via their clinical system, particularly related to the Quality and Outcomes Framework. The integration of eRATs into routine practice could be engendered by improvement to the training packages that accompany them, and by its delivery via a platform compatible with all GP clinical systems.

This paper aims to provide a detailed analysis of the diagnostic process of lung cancer from a primary-care perspective.

Diagnosing lung cancer at a stage where curative treatment is possible remains a challenge. Beginning to understand the complexity and difficulty in the diagnostic journey should enable the development of interventions in order to facilitate timelier diagnosis.

A national study of significant events was conducted whereby general practitioners (GPs) in Wales were asked to report data relating to the diagnostic process of recent lung cancer diagnoses using a standard template. Both qualitative and quantitative data were analysed.

Case reports were received from 96 general practices on 118 patients. A total of 96 patients (81.4%) presented with respiratory symptoms. A total of 79 patients (66.9%) had a GP-initiated X-ray before diagnosis. A total of 23 patients (19.5%) had a chest X-ray that did not initially show suspicion of lung cancer. A total of 25 patients (21.2%) were diagnosed after a GP-initiated acute admission. Analysis of free-text qualitative data showed that, for many patients, their GP behaved in an exemplary manner. However, for some patients, the GP could have made more of the opportunities presented for timelier diagnosis. There were a number of atypical and complex presentations, where the opportunities for more timely diagnosis were more limited. A variety of causes of diagnostic delays in secondary care were reported. These findings will inform health policy, and will inform the design of interventions to try to facilitate more timely diagnosis for symptomatic patients. We encourage greater compliance with diagnostic guidelines and greater vigilance for patients presenting with atypical symptoms, as well as for patients whose initial chest X-rays are normal.

To describe the role, contribution and value of research nurses in New Zealand community-based or primary health care research.

Research nurses are increasingly recognised as having a key role in undertaking successful research in hospitals and clinical trial units however only limited work has been undertaken to examine their role in community-based research. Undertaking health research in the community has unique challenges particularly in relation to research design and recruitment and retention of participants.

We describe four community-based research projects involving research nurses, each with particular recruitment, retention and logistical problems. Vignettes are used to illustrate the role, contribution and value of research nurses in a diverse range of community research projects.

The knowledge and skills used by research nurses in these projects included familiarity with communities, cultural competence, health care systems and practice philosophies and in particular with vulnerable populations. Their research actions and activities include competence with a broad range of research methodologies, organisational efficiency, family-centred approach, along with advocacy and flexibility. These are underpinned by nursing knowledge and clinical expertise contributing to an ability to work autonomously. These four projects demonstrate that research nurses in community-based research possess specific attributes which facilitate successful study development, implementation and outcome.

The National Institute of Clinical Excellence suggested black ethnic minorities with epilepsy have different cultural, communicative and health-care needs. However, little is known about these despite increasing migration of black African and Caribbean people to Europe. This study aims to explore perceptions and experiences of epilepsy among black African and Caribbean people in South London.

Semi-structured interviews were undertaken with 11 participants, to examine their beliefs and perceptions of living with epilepsy. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken.

African participants described supernatural causes for epilepsy and experienced considerable stigma whereas Caribbean participants described epilepsy as a ‘normal illness’. However, both African and Caribbean participants experienced social restrictions arising from their epilepsy.

The findings of higher levels of perceived stigma and social restriction seen in African participants may be a continuation of beliefs reported in participants’ country of origin. There is also evidence that views regarding epilepsy transition through generations vary depending on place of birth.

Health-care professionals need to be aware of and engage with the particular beliefs and concerns of black African and Caribbean people to achieve equity in health outcomes.

The Greek primary health-care system (PHC) seems to be suffering the most from the economic crisis because of understaffing and misdistribution of the health workforce and the shortage of medical supplies and diagnostic equipment.

The objective of the paper is to present for the first time in public national health-care workforce census data for the first two years of the economic recession and the adopted bailout mechanism (2010 and 2011) (a) to evaluate the adequacy of the governmental effort in terms of organization and management of the health-care workforce in PHC; and (b) to identify constraints and opportunities for the development of an integrated PHC ensuring access to health-care services for all.

Data were drawn from the national project ‘Health Monitoring Indicators System: Health Map’ coordinated scientifically by the National School of Public Health, Department of Epidemiology. They referred to the 202 PHCs and their regional surgeries (with 98% response rate). Descriptive statistics and frequency distributions were used for the analysis.

The findings pointed that PHC absorbs a very limited part of the national health system's workforce. Important inequalities in the numerical and geographical allocation of the PHC health workforce specialties across the country in favor of the medical profession and to the detriment of rural areas and the islands were identified, raising concerns about the policymakers’ ability to meet the emerging needs of the population, as the retrospective study of the health-care workforce, since 2010, reveals that the numerical and per type allocations remained almost unchanged. These results were in line with previous studies showcasing the lack of holistic approach for PHC questioning the restrictive spending policy (ie, salary and benefit cuts for the health-care professionals, important discharges and nonrenewal of the personnel) adopted in the public health-care sector.

The aim of the study was to determine whether positive psychological interventions (PPIs) in a primary health care setting would improve physical and mental health over time.

Most treatments for depression focus on reducing symptoms rather than on creating positive states of mental health. Empirical studies to verify the efficacy of PPIs in primary health care are needed.

In a six-week pilot program, we invited patients in a primary health care setting with symptoms of depression to participate in groups designed to increase levels of happiness. The program involved interventions such as engaging in good deeds, writing gratitude letters, and introducing empirical research. Patients completed the SF12v2® at the beginning and end of the program and at three- and six-month follow-up. Measures included physical functioning, bodily pain, mental health, social functioning, and vitality. Patients also participated in focus groups to discuss their experiences.

Of the 124 patients who enrolled in this pilot study, 75 completed the six-week program, and 35 participated in two follow-up assessments. Among the participants who remained for all follow-up assessments, scores improved from baseline to 6-month follow-up for health, vitality, mental health, and the effects of mental and physical health on daily activities. This subset of patients reported greater energy and more daily accomplishments, along with reductions in functional limitations. Improvements in mental and physical health and functioning were shown over a six-month period. The study provides a basis for the further investigation of PPIs in creating improvements for patients with depression in primary health care.

To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews.

Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care – the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting.

Design: A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions. Scope: Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions. Outcome measures: A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions.

Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions.

Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.

To explore maternal perceptions of supervision and childhood unintentional injury in order to develop understanding and explanation for differences in unintentional injury rates between an advantaged and disadvantaged area.

Unintentional injury is the second cause of mortality and a significant cause of morbidity in the zero to four year age group. Children living in socio-economic disadvantage are at a greater risk of unintentional injury than their more affluent counter-parts.

Qualitative study using semi-structured interviews; content data analysis was undertaken. Participants included 37 mothers with a child aged less than five years; 16 living in an area of disadvantage (and high rate of childhood unintentional injury) and 21 living in an advantaged area (and low rate of childhood unintentional injury).

Parents in both areas described the importance of parental supervision in reducing child unintentional injury risks. Parents in both areas used listening as a supervision strategy. Parents in both areas described how ‘when the child goes quiet’ that is a cue for them to make a visual check on the child. Listening was used more for boys than girls in both areas, but parents in the advantaged area used listening as a supervision strategy more frequently than those in the disadvantaged area. Parents described supervision strategies as being shaped by child character and age rather than child gender. Parents in both areas described similar strategies for managing distractions. An important difference was found with regard to older siblings; parents living in the advantaged area described older siblings as an injury risk to younger children. Parents in the disadvantaged area described older siblings as providing some supervision for younger children. Parents living in disadvantaged circumstances may face greater challenges with regard to supervision than parents living in advantaged circumstances and this may partly explain differences in injury risk.

To produce a user-friendly list of metastatic spinal cord compression (MSCC) Red Flags for non-specialist ‘generalist’ front-line clinicians working in primary-care settings.

The issue of identifying MSCC early to prevent serious long-term disability was a key theme identified by the Task and Finish Group at Greater Manchester and Cheshire Cancer Network (GMCCN) in 2009. It was this group who initially brokered and then coordinated the current development as part of their strategic approach to improving care for MSCC patients.

A consensus-building approach that considered the essential minimum data requirements to raise the index of suspicion suggestive of MSCC was adopted. This followed a model of cross-boundary working to facilitate the mutual sharing of expertise across a variety of relevant clinical specialisms.

A guideline aimed at helping clinicians to identify the early signs and symptoms of MSCC was produced in the form of a credit card. This credit card includes key statements about MSCC, signposting to key sources of additional information and a user-friendly list of Red Flags which has been developed into an eight-item Red Flag mnemonic. To date, an excess of 120 000 cards have been printed by a variety of organisations and the distribution of the cards is ongoing across the United Kingdom and the Republic of Ireland.