Geva Greenfield

Wake up, wake up! It’s me! It’s my life! patient narratives on person-centeredness in the integrated care context: a qualitative study

BackgroundPerson-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient’s world. Patient-centeredness has been commonly defined through physician’s behaviors aimed at delivering patient-centered care. Yet, it is unclear how ‘person-centeredness’ is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context.MethodsWe conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison.ResultsWe identified six themes representing core ‘ingredients’ of person-centeredness in the integrated care context: “Holism”, “Naming”, “Heed”, “Compassion”, “Continuity of care”, and “Agency and Empowerment“, all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt ‘unseen’ by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional ‘Space’ to be ‘seen’ and heard vs. feeling ‘translucent’, ‘unseen’, and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a ‘dyad’, the meanings patients attributed to ‘care’, and the theoretical correspondence between ‘person-centeredness’ and ‘integrated care’.ConclusionsPerson-centeredness is a crucial issue for patients in integrated care, yet it was variably achieved in the current pilot. Patients in the context of integrated care, as in other contexts, strive to have their own unique physical and emotional ‘space’ to be ‘seen’ and heard. Integrated care models can benefit from incorporating person-centeredness as a core element.

Rethinking primary care's gatekeeper role.

Geva Greenfield and colleagues ask whether it is time to reconsider the role of the GP as gatekeeper to specialist services, and call for more evidence to guide future policy

Achieving Provider Engagement Providers’ Perceptions of Implementing and Delivering Integrated Care

The literature on integrated care is limited with respect to practical learning and experience. Although some attention has been paid to organizational processes and structures, not enough is paid to people, relationships, and the importance of these in bringing about integration. Little is known, for example, about provider engagement in the organizational change process, how to obtain and maintain it, and how it is demonstrated in the delivery of integrated care. Based on qualitative data from the evaluation of a large-scale integrated care initiative in London, United Kingdom, we explored the role of provider engagement in effective integration of services. Using thematic analysis, we identified an evolving engagement narrative with three distinct phases: enthusiasm, antipathy, and ambivalence, and argue that health care managers need to be aware of the impact of professional engagement to succeed in advancing the integrated care agenda.

Truck drivers’ perceptions on wearable devices and health promotion: a qualitative study

BackgroundProfessional truck drivers, as other shift workers, have been identified as a high-risk group for various health conditions including cardiovascular disease, obesity, diabetes, sleep apnoea and stress. Mobile health technologies can potentially improve the health and wellbeing of people with a sedentary lifestyle such as truck drivers. Yet, only a few studies on health promotion interventions related to mobile health technologies for truck drivers have been conducted. We aimed to explore professional truck drivers’ views on health promotion delivered via mobile health technologies such as wearable devices.MethodsWe conducted a phenomenological qualitative study, consisting of four semi-structured focus groups with 34 full-time professional truck drivers in the UK. The focus groups were audio-taped, transcribed verbatim and analysed using thematic content analysis. We discussed drivers’ perceptions of their health, lifestyle and work environment, and their past experience and expectations from mobile health technologies.ResultsThe participants viewed their lifestyle as unhealthy and were aware of possible consequences. They expressed the need and wish to change their lifestyle, yet perceived it as an inherent, unavoidable outcome of their occupation. Current health improvement initiatives were not always aligned with their working conditions. The participants were generally willing to use mobile health technologies such as wearable devices, as a preventive measure to avoid prospect morbidity, particularly cardiovascular diseases. They were ambivalent about privacy and the risk of their employer’s monitoring their clinical data.ConclusionsWearable devices may offer new possibilities for improving the health and wellbeing of truck drivers. Drivers were aware of their unhealthy lifestyle. They were interested in changing their lifestyle and health. Drivers raised concerns regarding being continuously monitored by their employer. Health improvement initiatives should be aligned with the unique working conditions of truck drivers. Future research is needed to examine the impact of wearable devices on improving the health and wellbeing of professional drivers.

Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): study protocol for a randomised controlled trial

BackgroundNational guidelines in the UK, United States of America, Canada, and Australia have recently stressed the importance of identifying and treating antenatal anxiety and depression. However, there is little research into the most effective and acceptable ways of helping women manage their symptoms of anxiety and stress during pregnancy. Research indicates the necessity to consider the unique needs and concerns of perinatal populations to ensure treatment engagement, highlighting the need to develop specialised treatments which could be integrated within routine antenatal healthcare services. This trial aims to develop a brief intervention for antenatal anxiety, with a focus on embedding the delivery of the treatment within routine antenatal care.Methods/DesignThis study is a two-phase feasibility trial. In phase 1 we will develop and pilot a brief intervention for antenatal anxiety, blended with group support, to be led by midwives. This intervention will draw on cognitive behavioural principles and wider learning from existing interventions that have been used to reduce anxiety in expectant mothers. The intervention will then be tested in a pilot randomised controlled trial in phase 2. The following outcomes will be assessed: (1) number of participants meeting eligibility criteria, (2) number of participants consenting to the study, (3) number of participants randomised, (4) number of sessions completed by those in the intervention arm, and (5) number of participants completing the post-intervention outcome measures. Secondary outcomes comprise: detailed feedback on acceptability, which will guide further development of the intervention; and outcome data on symptoms of maternal and paternal anxiety and depression, maternal quality of life, quality of couple relationship, mother-child bonding, infant temperament and infant sleep.DiscussionThe study will provide important data to inform the design of a future full-scale randomised controlled trial of a brief intervention for anxiety during pregnancy. This will include information on its acceptability and feasibility regarding implementation within current antenatal services, which will inform whether ultimately this provision could be rolled out widely in healthcare settings.Trial registrationCurrent Controlled Trials ISRCTN95282830. Registered on 29 October 2014.

Second Medical Opinion: Utilization Rates and Characteristics of Seekers in a General Population.

Background:Second opinion (SO) is common in medical practice and can reduce unnecessary risks and costs. To date, there is no population-based estimation of how many people seek SOs and what the characteristics of second-opinion seekers are. Objectives:To estimate how many people seek SOs, and what the characteristics of second-opinion seekers are. Methods:We conducted both a medical records analysis (n=1,392,907) and a cross-sectional national telephone survey with a representative sample of the general Israeli population (n=848, response rate=62%). In the medical records analysis, we linked consultations with specialists at community secondary care and private consultations using claims data. We developed a time-sensitive algorithm that identified potential SO instances. In both methods, we predicted the characteristics of second-opinion seekers using multivariate logistic regressions. Results:The medical records analysis and the survey findings were highly consistent, and showed that about sixth (14.9% in the medical records vs. 17.2% in the survey) of a general population sought a SO, mostly from orthopedic surgeons. Women, native-born, and established immigrants, people living in central urban areas or close to central urban areas, people with chronic conditions, and those who perceived their health status as not very good, were more likely to seek SOs than others. Conclusions:A considerable amount of people sought a SO. Certain patient profiles tended to seek SOs more than others. Such utilization patterns are important to devise policy regarding SOs, due to their implications on expenditure, policy, clinical outcomes, and patient satisfaction.

Staff perceptions on patient motives for attending GP-led urgent care centres in London: a qualitative study

Objectives General practitioner (GP)-led urgent care centres were established to meet the growing demand for urgent care. Staff members working in such centres are central in influencing patients’ choices about which services they use, but little is known about staff perceptions of patients’ motives for attending urgent care. We hence aimed to explore their perceptions of patients’ motives for attending such centres. Design A phenomenological, qualitative study, including semistructured interviews. The interviews were analysed using thematic content analysis. Setting 2 GP-led urgent care centres in 2 academic hospitals in London. Participants 15 staff members working at the centres including 8 GPs, 5 emergency nurse practitioners and 2 receptionists. Results We identified 4 main themes: ‘Confusion about choices’, ‘As if increase of appetite had grown; By what it fed on’, ‘Overt reasons, covert motives’ and ‘A question of legitimacy’. The participants thought that the centres introduce convenient and fast access for patients. So convenient, that an increasing number of patients use them as a regular alternative to their community GP. The participants perceived that patients attend the centres because they are anxious about their symptoms and view them as serious, cannot get an appointment with their GP quickly and conveniently, are dissatisfied with the GP, or lack self-care skills. Staff members perceived some motives as legitimate (an acute health need and difficulties in getting an appointment), and others as less legitimate (convenience, minor illness, and seeking quicker access to hospital facilities). Conclusions The participants perceived that patients attend urgent care centres because of the convenience of access relative to primary care, as well as sense of acuity and anxiety, lack self-care skills and other reasons. They perceived some motives as more legitimate than others. Attention to unmet needs in primary care can help in promoting balanced access to urgent care.

Seven-day access to NHS primary care: how does England compare with Europe?:

Political pressure to increase access to primary care is growing. In the face of ever increasing demand for healthcare, this increase in primary care aims to reduce the burden on urgent and secondary care services. Also part of a broader driver towards establishing a seven-day NHS service, this would require GP practices to extend their opening hours beyond their current obligatory 52.5 hours per week. However, benchmarking with other European systems demonstrates that normal in-hours general practice provision in England already exceeds that of most other European countries. Furthermore, patients in England express greater satisfaction with primary care access relative to many other European countries. The reality of demand for extension of GP opening hours in England remains unclear and evidence about whether additional primary care access decreases accident and emergency department use limited and inconclusive. Before significant investment in further extension of GP opening hours, more research is required to understand the effects of changes to inand outof-hours primary care provision on access and emergency use. Introduction Healthcare systems globally are facing an increasing demand for care under stable or decreasing resources. It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, thus promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. However, evidence for this is mixed.(1–3) In England’s National Health Service (NHS) there is political pressure to expand GP surgeries’ opening hours to progress towards a ‘seven-day NHS’.(4) When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care.(5) This paper examines England’s current in-hours GP services relative to those of European countries in order to better contextualize the debate on extending GP opening hours. Access to GP Provision in England and the EU English general practices are required to be open between core hours of 8am to 6:30pm, Monday to Friday, a total of 52.5 hours per week,(6) although 46% practices are closed to patients during some of those hours, with 18% closing by 3pm at least once per week.(7) In January 2017, the Prime Minister reaffirmed the Government’s pledge to provide patients in England with access to a general practitioner (GP) between 8am and 8pm, seven days per week.(8) As of April 2017, 20% of Clinical Commissioning Groups (CCGs) in England were providing some seven-day 8am-8pm routine GP appointments.(9) 85% of CCGs were meeting a target of having 60% of additional evening appointments booked; 71% were meeting the same target for Saturday appointments, and 68% for Sundays. However, this varied widely by location, with some areas seeing only modest uptake of weekend appointments (8% and 2%, respectively).(9) Despite a lack of uniform data on general practice opening hours in European countries, some information is available (Table 1). Of 31 countries, obligatory minimum weekly opening hours for primary care practices exists for all but 9 countries, varying from 20 hours in Austria to 52.5 in England.(6) General practice opening hours in other European countries vary depending on region and local demand. In Finland and Greece, urban practices offer extended opening hours compared with those in rural locations, whilst in other countries, such as Spain, some rural practices are open 24 hours per day. Countries without a statutory requirement for minimum opening hours may have standard or customary opening times; most of these data were unavailable. Table 1: Minimum opening hours in EU countries (6,10) Country Obligatory Minimum Hours Notes Belgium No Cyprus Yes 7:30am-2:30pm, with opening to 6pm one night per week Estonia Yes 8 hrs/day, Monday to Friday Finland No Typically, health centres are open 8am – 3pm or 4pm; centres in cities are usually open until 8pm

GPs should be rewarded for patient experience to encourage a person centred NHS.

The NHS’s Quality and Outcomes Framework no longer offers points for patient experience. But these are a good incentive to encourage general practitioners to offer person centred care, says Geva Greenfield

The impact of private online video consulting in primary care

Workforce and resource pressures in the UK National Health Service mean that it is currently unable to meet patients’ expectations of access to primary care. In an era of near-instant electronic communication, with mobile online access available for most shopping and banking services, people expect similar convenience in healthcare. Consequently, increasing numbers of web-based and smartphone apps now offer same-day ‘virtual consulting’ in the form of Internet video conferencing with private general practitioners. While affordable and accessible private primary care may be attractive to many patients, the existence of these services raises several questions. A particular concern, given continued development of antimicrobial resistance, is that some companies appear to use ease of access to treatment with antibiotics as an advertising strategy. We examine online video consulting with private general practitioners in the UK, considering its potential impact on patients and the National Health Service, and its particular relevance to antimicrobial stewardship.