Jon Dowell

Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

Abstract Objectives To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change. Design Qualitative focus group study consisting of 11 focus groups with 67 participants. Setting General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland. Sample Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes. Results General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes. Conclusions Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.

Electives: isn't it time for a change?

Objectives  Medical student electives are memorable learning experiences, of which approximately 40% are spent in developing countries. Students often have laudable motivation but are rarely helped to learn most effectively or contribute meaningfully whilst away. Each year an estimated 350 years of elective time is spent in developing countries (by students from the UK alone), which represents substantial opportunity.

Changing to generic formulary: how one fundholding practice reduced prescribing costs

Abstract Objectives: To observe one general practices attempt to reduce prescribing costs on becoming third wave fundholders through the introduction of a generic formulary applied to all new and repeat prescribing. To assess the impact on patients and prescribing patterns. Design: An observational study using interviews with patients and practitioners; questionnaires for patients and prescribing data. Setting: One urban general practice with five partners in Scotland. It became fundholding in April 1993. Subjects: 71 searches of the register of repeat prescriptions identified 1274 potential changes in drugs. Questionnaires were sent to a stratified random sample of 280 patients four months after the changes were made; 33 interviews were conducted with 17 patients selected by local pharmacists to represent a wide range of opinion. Main outcome measures: Changes in prescribing and response and satisfaction of patients. Results: Of intended changes, 129 (70%) were in place after four months. Thirty three (20%) of the 167 patients who returned questionnaires were “very unhappy,” though interviews suggested that this was primarily with the communication they received rather than the change itself. Generic prescribing rose from one in three (37%) to over a half (58%). The volume of treatment dispensed (as treatment days) fell by 67674 (10.7%), and the average cost per days treatment fell by 3.1p from 32.3p per day in 1992 (9.4%), producing a total absolute saving of 24% (pounds sterling137712) over the first year. Conclusion: This practice has achieved a large reduction in prescribing costs rapidly. These were tolerated by patients, none of whom is thought to have left the practice for this reason. Great care must be taken to inform patients appropriately. Key messages Key messages Financial incentives are increasingly being used to encourage cheaper prescribing It seems that patients will accept large scale changes, at least within the context of fundholding The introduction of such changes should be carefully planned, particularly the way in which patients are informed There is a need for more research into the balance between prescribing expenditure and the provision of other services

Audio-visual recording of patient–GP consultations for research purposes: A literature review on recruiting rates and strategies

OBJECTIVE To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants. METHODS A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search. RESULTS Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour. CONCLUSIONS Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed. PRACTICE IMPLICATIONS Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Does the UKCAT predict Year 1 performance in medical school

Context  The need to identify the best applicants for medicine and to ensure that selection is fair and ethical has led to the development of alternative, or additional, selection tools. One such tool is the United Kingdom Clinical Aptitude Test, or UKCAT. To date there have been no studies of the predictive validity of the UKCAT.

The multiple mini-interview in the UK context: 3 years of experience at Dundee

Background: The Multiple Mini-Interview (MMI) is a new interview process that Dundee Medical School has recently adopted to assess entrants into its undergraduate medicine course. This involves an ‘Objective Structured Clinical Examination’ like rotational approach in which candidates are assessed on specific attributes at a number of stations. Aims: To present methodological, questionnaire and psychometric data on the transitional process from traditional interviews to MMIs over a 3-year period and discuss the implications for those considering making this transition. Methods: To facilitate the transition, a four-station MMI was piloted in 2007. Success encouraged consideration of desirable attributes which were used to develop a full 10-station process which was implemented in 2009 with assessors being recruited from staff, students and simulated patients. A questionnaire was administered to all assessors and candidates who participated in the 2009 MMIs. Cronbachs alpha and Pearsons r and analysis of variances were used to determine the MMIs psychometric properties. Multi-faceted Rasch modelling (MFRM) was modelled to control for assessor leniency/stringency and the impact of using ‘fair scores’ determined. Analysis was conducted using SPSS 17 and FACETS 3.65.0. Results: The questionnaire confirmed that the process was acceptable to all parties. Cronbachs alpha reliability was satisfactory and consistent. Graduates/mature candidates outperformed UK school-leavers and overseas candidates. Using MFRM fair scores would change the selection outcome of 6.2% and 9.6% of candidates in 2009 and 2010, respectively. Students were less lenient, made more use of the full range of the rating scales and were just as reliable as staff. Conclusions: The strategy of generating institutional support through staged introduction proved effective. The MMI in Dundee was shown to be feasible and displayed sound psychometric properties. Student assessors appeared to perform at least as well as staff. Despite a considerable intellectual and logistical challenge MMIs were successfully introduced and deemed worthwhile.

Twelve tips for developing and maintaining a simulated patient bank

Simulated patients have become almost indispensable in the education and training of health care professionals. Their contribution to the creation of a safe, yet realistic, learner centred environment is invaluable. Their support in enabling learners at all stages of their professional careers to develop both competence and confidence through repeated practice helps to ensure that learning from real patients can be maximized. A simulated patient bank can enable tracking and training of simulated patients to be coordinated in an effective and efficient way both for patients and learners. This paper shares experiences of developing a simulated patient bank against the background of changes in health care delivery and education and training. Twelve tips to developing and maintaining a simulated patient bank have been identified. The tips focus on the needs of the simulated patient bank and ensure that training is at an appropriate level for the learners, patient care is not compromised and simulated patients feel they are valued members of the educational team.

“I’ve Never Not Had it So I Don’t Really Know What it’s Like Not to”: Nondifference and Biographical Disruption Among Children and Young People With Cystic Fibrosis

The relevance of biographical disruption and loss of self for children and young people is unclear, particularly in cases of congenital illness such as cystic fibrosis, where no prior period of wellness, stability, or perceived normality might exist. We explored the meaning, importance, and forms of maintenance of ideas of normality among 32 children and young people with cystic fibrosis. We examine the ways in which normalcy is produced, maintained, and threatened, and discuss the implications for the applicability and relevance of these traditional sociological concepts. Analysis of children’s and young people’s accounts resulted in a conceptualization of four forms of normalcy based on personal and social definitions and audiences. Biographical disruption appeared relevant but in a more nuanced form than its usual conceptualization when applied to adult populations. Maintaining normality within the family resulted in continual biographical revision in anticipation of future illness trajectory and life course.

Problems and solutions: Accounts by parents and children of adhering to chest physiotherapy for cystic fibrosis

Purpose. Although chest physiotherapy is central to the management of cystic fibrosis (CF), adherence among children is problematic. This study explores accounts by parents and children of the difficulties of adhering to chest physiotherapy for cystic fibrosis, and identifies strategies used by families to overcome these. Methods. A qualitative study based on in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7 – 17 years, and with 31 parents. Results. Physiotherapy was frequently described as restrictive, threatening to identity and boring, giving rise to feelings of unfairness, inequality, ‘difference’, and social stigma. Motivation to adhere was influenced by perceptions of effectiveness that depended on external signs evident during or after the physiotherapy. Motivation was enhanced where parents and children visualized the accumulation of mucus. Some parents had developed distraction techniques that improved the experience of chest physiotherapy but had few opportunities to share these with other parents. Conclusion. The experience of physiotherapy is problematic to some parents and children. Furthermore, motivation to overcome these problems may be undermined by perceptions of ineffectiveness. Distraction techniques that change the value that the child places on the time spent doing physiotherapy and that reduces their perception of its duration may improve experience and adherence. The potential of visualization techniques to promote adherence should be investigated further.

Fair access to medicine? Retrospective analysis of UK medical schools application data 2009-2012 using three measures of socioeconomic status.

BackgroundMedical students have historically largely come from more affluent parts of society, leading many countries to seek to broaden access to medical careers on the grounds of social justice and the perceived benefits of greater workforce diversity. The aim of this study was to examine variation in socioeconomic status (SES) of applicants to study medicine and applicants with an accepted offer from a medical school, comparing the four UK countries and individual medical schools.MethodsRetrospective analysis of application data for 22 UK medical schools 2009/10-2011/12. Data were analysed for all 32,964 UK-domiciled applicants aged <20 years to 22 non-graduate medical schools requiring applicants to sit the United Kingdom Clinical Aptitude Test (UKCAT). Rates of applicants and accepted offers were compared using three measures of SES: (1) Postcode-assigned Index of Multiple Deprivation score (IMD); (2) School type; (3) Parental occupation measured by the National Statistics Socio Economic Classification (NS-SEC).ResultsThere is a marked social gradient of applicants and applicants with accepted offers with, depending on UK country of residence, 19.7–34.5 % of applicants living in the most affluent tenth of postcodes vs 1.8–5.7 % in the least affluent tenth. However, the majority of applicants in all postcodes had parents in the highest SES occupational group (NS-SEC1). Applicants resident in the most deprived postcodes, with parents from lower SES occupational groups (NS-SEC4/5) and attending non-selective state schools were less likely to obtain an accepted offer of a place at medical school further steepening the observed social gradient. Medical schools varied significantly in the percentage of individuals from NS-SEC 4/5 applying (2.3 %–8.4 %) and gaining an accepted offer (1.2 %–7.7 %).ConclusionRegardless of the measure, those from less affluent backgrounds are less likely to apply and less likely to gain an accepted offer to study medicine. Postcode-based measures such as IMD may be misleading, but individual measures like NS-SEC can be gamed by applicants. The previously unreported variation between UK countries and between medical schools warrants further investigation as it implies solutions are available but inconsistently applied.