David Blane

The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study

Background Multimorbidity occurs at a younger age in individuals in areas of high socioeconomic deprivation but little is known about the ‘typology’ of multimorbidity in different age groups and its association with socioeconomic status. Aim To characterise multimorbidity type and most common conditions in a large nationally representative primary care dataset in terms of age and deprivation. Design and setting Cross-sectional analysis of 1 272 685 adults in Scotland. Method Multimorbidity type of participants (physical-only, mental-only, mixed physical, and mental) and most common conditions were analysed according to age and deprivation. Results Multimorbidity increased with age, ranging from 8.1% in those aged 25–34 to 76.1% for those aged ≥75 years. Physical-only (56% of all multimorbidity) was the most common type of multimorbidity in those aged ≥55 years, and did not vary substantially with deprivation. Mental-only was uncommon (4% of all multimorbidity), whereas mixed physical and mental (40% of all multimorbidity) was the most common type of multimorbidity in those aged <55 years and was two- to threefold more common in the most deprived compared with the least deprived in most age groups. Ten conditions (seven physical and three mental) accounted for the top five most common conditions in people with multimorbidity in all age groups. Depression and pain featured in the top five conditions across all age groups. Deprivation was associated with a higher prevalence of depression, drugs misuse, anxiety, dyspepsia, pain, coronary heart disease, and diabetes in multimorbid patients at different ages. Conclusion Mixed physical and mental multimorbidity is common across the life-span and is exacerbated by deprivation from early adulthood onwards.

The claim for patient choice and equity

Recently, commentators close to and within the UK government have claimed that patient choice can increase equity in the context of the National Health Service. This article critically examines the basis for this claim through analysis of recent speeches and publications authored by secretaries of state for health and their policy advisers. It is concluded that this claim has not developed prospectively from an analysis of the causes of healthcare inequity, or even with a consistent normative definition of equity. The limited justification that is “framed in causal explanations” of inequity has suffered from an apparent disregard of the available evidence.

Qualitative systematic reviews of treatment burden in stroke, heart failure and diabetes - Methodological challenges and solutions

BackgroundTreatment burden can be defined as the self-care practices that patients with chronic illness must perform to respond to the requirements of their healthcare providers, as well as the impact that these practices have on patient functioning and well being. Increasing levels of treatment burden may lead to suboptimal adherence and negative outcomes. Systematic review of the qualitative literature is a useful method for exploring the patient experience of care, in this case the experience of treatment burden. There is no consensus on methods for qualitative systematic review. This paper describes the methodology used for qualitative systematic reviews of the treatment burdens identified in three different common chronic conditions, using stroke as our exemplar.MethodsQualitative studies in peer reviewed journals seeking to understand the patient experience of stroke management were sought. Limitations of English language and year of publication 2000 onwards were set. An exhaustive search strategy was employed, consisting of a scoping search, database searches (Scopus, CINAHL, Embase, Medline & PsycINFO) and reference, footnote and citation searching. Papers were screened, data extracted, quality appraised and analysed by two individuals, with a third party for disagreements. Data analysis was carried out using a coding framework underpinned by Normalization Process Theory (NPT).ResultsA total of 4364 papers were identified, 54 were included in the review. Of these, 51 (94%) were retrieved from our database search. Methodological issues included: creating an appropriate search strategy; investigating a topic not previously conceptualised; sorting through irrelevant data within papers; the quality appraisal of qualitative research; and the use of NPT as a novel method of data analysis, shown to be a useful method for the purposes of this review.ConclusionThe creation of our search strategy may be of particular interest to other researchers carrying out synthesis of qualitative studies. Importantly, the successful use of NPT to inform a coding frame for data analysis involving qualitative data that describes processes relating to self management highlights the potential of a new method for analyses of qualitative data within systematic reviews.

Identifying treatment burden as an important concept for end of life care in those with advanced heart failure.

Purpose of reviewThe concept of treatment burden is receiving increasing attention and this review seeks to show that treatment burden is an important issue for end-of-life care in those with advanced heart failure. Recent findingsReview of the qualitative literature on patient experience of end-stage heart failure since the year 2000, including 2012, suggests that treatment burden, the work that patients have to do to manage their condition, is a readily identifiable concept in advanced heart failure. Treatment burden relates to four main areas of work, namely: coherence (sense making work) which refers to the work of developing an understanding of the illness (including its implications), treatment and management; appraisal, which refers to the work of judging, monitoring and adjusting treatments; relationship work which describes the effort put into engaging with others for support; and enacting work, that is the effort put into operationalizing treatments, which includes activities such as taking medications, attending appointments, enduring side effects of treatments and dealing with communication difficulties. SummaryTreatment burden has the potential to be an important barometer of quality of care from the patient perspective in advanced heart failure.

The role of empathy in therapy and the physician-patient relationship.

This paper seeks to give an overview of the role of clinical empathy in therapy and in the physician-patient relationship. Researchers have offered definitions of empathy in the clinical context, and a number of validated measures exist. There is evidence from the health-related research literature to support the positive association of clinical empathy with improved therapeutic outcomes in a wide range of clinical settings. Clinical empathy is also understood to be a crucial component of the physician-patient therapeutic relationship. Barriers to the development and expression of empathy in the clinical context are explored, and ways of enhancing empathy discussed.

Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

BackgroundObesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process.MethodsRealist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components.DiscussionThis is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions.Systematic review registrationPROSPERO CRD42014009391

Distribution of GPs in Scotland by age, gender and deprivation

General practice in the UK is widely reported to be in crisis, with particular concerns about recruitment and retention of family doctors. This study assessed the distribution of GPs in Scotland by age, gender and deprivation, using routinely available data. We found that there are more GPs (and fewer patients per GP) in the least deprived deciles than there are in the most deprived deciles. Furthermore, there are a higher proportion of older GPs in the most deprived deciles. There are also important gender differences in the distribution of GPs. We discuss the implications of these findings for policymakers and practitioners.

Attitudes towards health inequalities amongst GP trainers in Glasgow, and their ideas for changes in training.

WHAT IS ALREADY KNOWN IN THIS AREA: Recent government policy has emphasised the important role that GPs have to play in addressing health inequalities. The RCGP curriculum asserts the importance of gaining a better understanding of health inequalities during GP training. GP training in Scotland continues to take place in disproportionately affluent areas. WHAT THIS WORK ADDS: This is the first study to look at attitudes of GP trainers towards health inequalities and to explore their ideas for changes in training that may address health inequalities. There were noticeable differences in the views of GP trainers--both in terms of the causes of health inequalities and the role of primary care in tackling inequalities--depending on whether they were based in more affluent or more deprived practices. Practice rotations were suggested by all groups as a means to give GP trainees exposure to the particular challenges of both affluent and deprived practice populations. SUGGESTIONS FOR FUTURE RESEARCH: Pilot studies of practice rotations between deprived and affluent areas would be of value. Evaluation of nMRCGP assessments (particularly the Clinical Skills Assessment, CSA) with regard to representativeness of general practice in deprived areas should be considered. Further qualitative research into the attitudes of GP trainees towards health inequalities, and GP trainers from different--less deprived--practice areas, would also be of interest. [corrected].

Cognitive behavioural therapy: why primary care should have it all

Cognitive behavioural therapy (CBT) is a short-term treatment that aims to change unhelpful patterns of thinking or behaviour that can contribute to maintaining or worsening various mental or physical health problems. Its potential applications are widespread. In the UK, the National Institute for Health and Clinical Excellence (NICE) recommends CBT as an option for treatment of a wide range of mental health conditions, including depression, anxiety, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and bulimia nervosa. CBT can also be used in sleeping disorders, to cope with a range of physical health problems such as pain and fatigue, as well as for phobias, substance misuse disorders (including smoking cessation), and functional disorders/ medically unexplained symptoms. The traditional model of CBT (1 hour sessions for 12–20 weeks) can be used across age groups (including children, young people, and older adults) and can be delivered using a variety of methods (face-to-face, in groups/classes, by telephone). Although originally the preserve of secondary care psychiatry and psychology services, CBT has increasingly been applied in primary care settings as a first step in care. The majority of published research on the use of CBT in primary care has been in individuals with depression, with improved outcomes demonstrated for both mild-tomoderate1 and major depression,2 when compared to usual care. CBT is ideally suited to breaking the unhelpful ‘thoughtsfeelings-behaviours’ cycles associated with depression, anxiety, and related disorders such as PTSD and OCD. However, there is growing evidence for the use …

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study.

Objective To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS). Design Cross-sectional study. Setting Regional specialist WMS located in the West of Scotland. Participants 9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing. Primary and secondary outcome measures Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions. Analysis Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion. Results Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18–24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30–35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas. Conclusions There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation.