Jeremy Dale

Improving generalist end of life care: national consultation with practitioners, commissioners, academics, and service user groups

Objective To identify major concerns of national and local importance in the provision, commissioning, research, and use of generalist end of life care. Design A national consultation and prioritising exercise using a modified form of the nominal group technique. Participants Healthcare practitioners, commissioners, academics, and representatives of user and voluntary groups. Setting Primary and secondary care, specialist palliative care, and academic and voluntary sectors in England and Scotland. Results 74% of those invited (210/285) participated. The stage of life to which “end of life care” referred was not understood in a uniform way. Perceptions ranged from a period of more than a year to the last few days of life. Prominent concerns included difficulties in prognosis and the availability of adequate support for patients with advanced non-malignant disease. Generalists in both primary and secondary care were usually caring for only a few patients approaching the end of life at any one time at a point in time. It was therefore challenging to maintain skills and expertise particularly as educational opportunities were often limited. End of life care took place among many other competing and incentivised activities for general practitioners in the community. More needs to be known about models of end of life care and how these can be integrated in a generalist’s workload. A greater evidence base is needed about the effectiveness and application of current tools such as the gold standards framework and Liverpool care pathway and about models of palliation in patients with diseases other than cancer. Conclusions Definitions of end of life care need clarification and standardisation. A greater evidence base is needed to define models of good practice together with a commitment to provide education and training and adequate resources for service provision. More needs to be known about the context of provision and the influence of competing priorities and incentives.

What is the effect of peer support on diabetes outcomes in adults? A systematic review

Aim  There is increasing interest in the role that peers may play to support positive health behaviours in diabetes, but there is limited evidence to inform policy and practice. The aim of this study was to systematically review evidence of the impact and effectiveness of peer support in adults living with diabetes.

Primary care in the accident and emergency department: II. comparison of general practitioners and hospital doctors

Abstract Objective:To compare the process and outcome of “primary care” consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department. Design:Prospective, controlled intervention study. Setting:A busy, inner city accident and emergency department in south London. Subjects:Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars. Main outcome measures:Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations. Results:Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners. Conclusion:Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Telephone peer-delivered intervention for diabetes motivation and support: The telecare exploratory RCT

OBJECTIVE To test trial design issues related to measuring the effectiveness of a peer telephone intervention to enhance self-efficacy in type 2 diabetes; evaluate the impact on self-efficacy and clinical outcome; and describe patient and peer experience. METHODS Eligible patients had raised HbA1c (initial threshold >8%, reduced to >7.4% mid-way through trial). Patients were recruited from 40 general practices and randomised (40:40:20 ratio) to receive routine care alone or, in addition, motivational telephone support from a peer supporter or a diabetes specialist nurse (9 peers and 12 DSNs) for a period of up to 6 months. The primary outcome measure was self-efficacy score, and secondary outcome measures included HbA1c. Patient and telecare supporter satisfaction and experience were evaluated. RESULTS In all, 231 patients participated. At 6 months there were no statistically significant differences in self-efficacy scores (p=0.68), HbA1c (p=0.87) or other secondary outcome measures. There was evidence of a high level of acceptability, but peer telecare support was less highly valued than that from a DSN. Some patients stated that they would have valued more information and advice. CONCLUSIONS Further consideration needs to be given to the targeting of the telecare peer support, its intensity, the training and ongoing supervision of peer supporters, and the extent to which information and advice should be incorporated. PRACTICE IMPLICATIONS While some patients with poorly controlled type 2 diabetes value peer telephone support, this approach appears not to suit all patients. Further intervention development and evaluation is required before widespread adoption can be recommended.

Exploring preferences for place of death with terminally ill patients: qualitative study of experiences of general practitioners and community nurses in England

Objective To explore the experiences and perceptions of general practitioners and community nurses in discussing preferences for place of death with terminally ill patients. Design Qualitative study using semistructured interviews and thematic analysis. Participants 17 general practitioners and 19 nurses (16 district nurses, three clinical nurse specialists). Setting 15 general practices participating in the Gold Standards Framework for palliative care from three areas in central England with differing socio-geography. Practices were selected on the basis of size and level of adoption of the standards framework. Results All interviewees bar one had experience of discussing preferred place of death with terminally ill patients. They reported that preferences for place of death frequently changed over time and were often ill defined or poorly formed in patients’ minds. Preferences were often described as being co-created in discussion with the patient or, conversely, inferred by the health professional without direct questioning or receiving a definitive answer from the patient. This inherent uncertainty challenged the practicability, usefulness, and value of recording a definitive preference. The extent to which the assessment of enabling such preferences can be used as a proxy for the effectiveness of palliative care delivery is also limited by this uncertainty. Generally, interviewees did not find discussing preferred place of death an easy area of practice, unless the patient broached the subject or led the discussions. Conclusions Further research is needed to enable development of appropriate training and support for primary care professionals. Better understanding of the importance of place of death to patients and their carers is also needed.

NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious

Ambulance services and emergency departments are under increasing pressure as the number of emergency calls continues to rise—but in many cases, patients do not need immediate clinical care. Helen Snooks and colleagues consider the alternatives to the standard NHS response and review the current literature The number of emergency (999) calls received by ambulance services in the United Kingdom has risen consistently over recent years. Ambulance services must respond to calls immediately by sending vehicles staffed by paramedics, with flashing lights and sirens. All patients have to be taken to an accident and emergency department. This response is not always appropriate, and it can resultin inefficient use of resources and unnecessary risks to the general public, patients, and paramedics. The NHS Plan and the recent consultation document Reforming Emergency Care have emphasised the importance of trying new approaches to deliver appropriate care. 1 2 They highlight the need to consider new ways to integrate the ambulance response to 999 calls into the overall system that deals with emergencies. ### Summary points Demands on emergency services and inappropriate requests for emergency ambulances are increasing Ambulance services must respond to calls immediately by sending vehicles with flashing lights and sirens, staffed by paramedics Many ambulance services want to develop alternatives to the standard response to all 999 calls Evidence about the safety and effectiveness of alternatives is weak and few rigorous trials have been reported Studies show that alternative responses are needed but that the work involved in their development is complex In England, demand through the 999 telephone system for services has risen by 40% since 1990.3 Problems of overcrowding and high attendance have also been noted in emergency departments and in primary care. Concerns have been expressed over the number of home visits requested at night and whether all such visits are …

Clinical and cost effectiveness of mechanical support for severe ankle sprains: design of a randomised controlled trial in the emergency department [ISRCTN 37807450]

BackgroundThe optimal management for severe sprains (Grades II and III) of the lateral ligament complex of the ankle is unclear. The aims of this randomised controlled trial are to estimate (1) the clinical effectiveness of three methods of providing mechanical support to the ankle (below knee cast, Aircast® brace and Bledsoe® boot) in comparison to Tubigrip®, and (2) to compare the cost of each strategy, including subsequent health care costs.Methods/designSix hundred and fifty people with a diagnosis of severe sprain are being identified through emergency departments. The study has been designed to complement routine practice in the emergency setting. Outcomes are recovery of mobility (primary outcome) and usual activity, residual symptoms and need for further medical, rehabilitation or surgical treatment. Parallel economic and qualitative studies are being conducted to aid interpretation of the results and to evaluate the cost-effectiveness of the interventions.DiscussionThis paper highlights the design, methods and operational aspects of a clinical trial of acute injury management in the emergency department.

Obstacles to adherence in living with type-2 diabetes: An international qualitative study using meta-ethnography (EUROBSTACLE)

Quantitative studies failed to determine variables which consistently explain adherence or non-adherence to treatment recommendations. Qualitative studies identified issues such as the quality of the health provider-health receiver relationship and the patients health beliefs. According to these findings, 39 focus groups of 246 people living with type-2 diabetes were conducted in seven European countries, assessing health beliefs, communication with caregivers and problems encountered in adhering to treatment regimens. Meta-ethnography was later applied to make a qualitative meta-analysis. Obstacles to adherence are common across countries, and seem to be related less to issues of the health-care system and more to patients knowledge about diabetes, beliefs and attitudes and the relationship with health-care professionals. The resulting key themes are course of diabetes, information, person and context, body awareness and relationship with the health care provider. Meta-ethnography is a feasible tool for the meta-analysis of multilingual qualitative data and leads to a richer account.

On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature

With rising demand and recognition of the variety of cases attended by emergency ambulance crews, services have been considering alternative ways of providing non-urgent care. This paper describes and appraises the research literature concerning on-scene alternatives to conveyance to an emergency department, focusing on the: (1) profile and outcomes of patients attended but not conveyed by emergency crews; (2) triage ability of crews; (3) effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self care. The literature search was conducted through standard medical databases, supplemented with manual searches. Very few “live” studies were identified, and fewer still that included a control group. Findings indicated a complex area, with the introduction of protocols allowing crews to leave patients at scene carrying clinical risk. Robust research evidence concerning alternatives to current emergency care models is needed urgently to inform service and practice development.

Effects of the Diabetes Manual 1:1 structured education in primary care

Aims  To determine the effects of the Diabetes Manual on glycaemic control, diabetes‐related distress and confidence to self‐care of patients with Type 2 diabetes.