Shamini Gnani

Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions.

BACKGROUND Inappropriate attendances may account for up to 40% of presentations at accident and emergency (A&E) departments. There is considerable interest from health practitioners and policymakers in interventions to reduce this burden. AIM To review the evidence on primary care service interventions to reduce inappropriate A&E attendances. DESIGN AND SETTING Systematic review of UK and international primary care interventions. METHOD Studies published in English between 1 January 1986 and 23 August 2011 were identified from PubMed, the NHS Economic Evaluation Database, the Cochrane Collaboration, and Health Technology Assessment databases. The outcome measures were A&E attendances, patient satisfaction, clinical outcome, and intervention cost. Two authors reviewed titles and abstracts of retrieved results, with adjudication of disagreements conducted by the third. Studies were quality assessed using the Scottish Intercollegiate Guidelines Network checklist system where applicable. RESULTS In total, 9916 manuscripts were identified, of which 34 were reviewed. Telephone triage was the single best-evaluated intervention. This resulted in negligible impact on A&E attendance, but exhibited acceptable patient satisfaction and clinical safety; cost effectiveness was uncertain. The limited available evidence suggests that emergency nurse practitioners in community settings and community health centres may reduce A&E attendance. For all other interventions considered in this review (walk-in centres, minor injuries units, and out-of-hours general practice), the effects on A&E attendance, patient outcomes, and cost were inconclusive. CONCLUSION Studies showed a negligible effect on A&E attendance for all interventions; data on patient outcomes and cost-effectiveness are limited. There is an urgent need to examine all aspects of primary care service interventions that aim to reduce inappropriate A&E attendance.

Ethnic disparities in diabetes management: a 10-year population-based repeated cross-sectional study in UK primary care

BACKGROUND There has been little research on the impact of quality improvement initiatives on ethnic disparities in diabetes management in the UK. METHODS Population-based, repeated cross-sectional survey of recorded measurements, prescribing and achievement of treatment targets among 4309 patients with diabetes mellitus using electronic medical records from 26 general practices in North-West London from 1997 to 2006. RESULTS Proportions of patients having their blood pressure (BP), cholesterol and HbA1c measured and recorded increased over the study period [from 50.6% to 87.0% (P < 0.0001), 17.0% to 76.7% (P < 0.0001) and 32.9% to 74.1% (P < 0.0001), respectively]. However, some ethnic differences remained. Black patients with diabetes were less likely to achieve target BP (<140/80 mmHg) than the white group [2006 age-sex adjusted odds ratio (AOR), 0.65; 95% confidence interval (CI), 0.51-0.83]. South Asians were found to have better lipid target control (2006 AOR, 1.57; CI, 1.23-2.00), were more likely to receive oral hypoglycaemic agents (2006 AOR, 2.27; CI, 1.79-2.86) but less likely to receive insulin (2006 AOR, 0.54; CI, 0.42-0.69) than the white group. CONCLUSIONS Although ethnic disparities persist in diabetes management in this study population, these are starting to be addressed, particularly in the South Asian group. All ethnic groups have benefited from recent quality initiatives in the UK.

Reasons for attending an urban urgent care centre with minor illness: a questionnaire study

Introduction The demand for urgent care is increasing, and the pressure on emergency departments is of significant concern. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients to more appropriate primary care environments. This study explores why patients with minor illness choose to attend an urban urgent care centre for their healthcare needs. Methods A self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival to an urgent care centre, colocated with an emergency department in London. Results Median participant age was 29 years. 58% (649/1112) of patients attending the centre with minor illness during the study period took part. 72% participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated themselves as healthy (81%). Access to care (58%) was a key reason for using the service as was expectation of receiving prescription medication (69%). GP dissatisfaction influenced 10% of participants in their decision to attend. 68% did not contact their GP in the previous 24 h before attending. Conclusions We found that the GP-led urgent care centre was similar to walk in centres in attracting healthy young adults, who were mostly registered with a GP and used services because of convenience and ease of access rather than satisfaction levels with their GP. This group may benefit from being seen as part of routine general practice care to provide opportunities for education and promotion of self-management.

Evaluation of a general practitioner-led urgent care centre in an urban setting: description of service model and plan of analysis

Estimates of patients attending with conditions deemed non-urgent or inappropriate for accident and emergency services vary widely, from 6 to 80%. Previous research suggests that general practitioners (GPs) working in emergency departments can reduce referral rates, diagnostic testing, the proportion of patients who become emergency hospital admissions, and inappropriate attendances. However, little of this previous research is recent and new models of care for GPs working in emergency departments have now been developed, which remain to be evaluated. In this paper, we describe an integrated urgent care model, which was commissioned by NHS Hammersmith and Fulham in 2009 to manage the rising number of urgent attendances at local hospitals and its associated evaluation. The evaluation will include examining the effect of the system on outcomes such as utilization of diagnostic tests and effect on unplanned hospital admissions. If the new model of care is shown to be both clinically effective and cost-effective, the model and the proposed plan of evaluation will also be helpful to other areas that are considering the introduction of similar models of GP-led urgent care.

Promoting mental health and preventing mental illness in general practice

Abstract This paper calls for the routine integration of mental health promotion and prevention into UK General Practice in order to reduce the burden of mental and physical disorders and the ensuing pressure on General Practice. The proposals & the resulting document (https://ethicscharity.files.wordpress.com/2015/09/rcgp_keymsg_150925_v5.pdf) arise from an expert ‘Think Tank’ convened by the London Journal of Primary Care, Educational Trust for Health Improvement through Cognitive Strategies (ETHICS Foundation) and the Royal College of General Practitioners. It makes 12 recommendations for General Practice: (1) Mental health promotion and prevention are too important to wait. (2) Work with your community to map risk factors, resources and assets. (3) Good health care, medicine and best practice are biopsychosocial rather than purely physical. (4) Integrate mental health promotion and prevention into your daily work. (5) Boost resilience in your community through approaches such as community development. (6) Identify people at increased risk of mental disorder for support and screening. (7) Support early intervention for people of all ages with signs of illness. (8) Maintain your biopsychosocial skills. (9) Ensure good communication, interdisciplinary team working and inter-sectoral working with other staff, teams and agencies. (10) Lead by example, taking action to promote the resilience of the general practice workforce. (11) Ensure mental health is appropriately included in the strategic agenda for your ‘cluster’ of General Practices, at the Clinical Commissioning Groups, and the Health and Wellbeing Board. (12) Be aware of national mental health strategies and localise them, including action to destigmatise mental illness within the context of community development.

HIV testing uptake and acceptability in an inner city polyclinic.

Abstract Up to 33% of HIV-infected adults in the UK remain undiagnosed and efforts to increase HIV testing are underway. HIV testing was conducted amongst individuals presenting to a polyclinic at a central London hospital using a point of care test. Demographic and HIV risk data was collected along with a patient feedback questionnaire exploring acceptability of the HIV testing experience. Seventy-one out of 93 (76%) individuals accepted HIV testing. Of those accepting HIV testing, 53/71 (75%) had never previously tested for HIV despite, 45/53 (85%) of these being registered with a GP. Twenty-seven out of 71 (38%) of individuals testing had at least one risk factor associated with HIV acquisition, and of these 17/27 (63%) had never previously tested for HIV infection. There were no new HIV positive diagnoses during the period of testing. Respondents indicated a high level of satisfaction with the service and more than 85% found the service to be helpful, educational and convenient. This small proof of concept pilot showed uptake of HIV testing in this setting to be high and acceptable to patients.

Referral outcomes of attendances at general practitioner-led urgent care centres in London, England: retrospective analysis of hospital administrative data

Objective To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England. Methods We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables—age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance—and the outcome of onwards referral to the co-located EDs or other hospital specialty departments. Results Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patients age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs. Conclusions The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.

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.

Patterns of healthcare use among adolescents attending an urban general practitioner-led urgent care centre

Introduction Adolescence is a time of increasing health and peak fitness, as well as increasing health risks. In the UK, primary care is free at the point of access, yet, adolescents aged 10–19 years are the lowest users of primary care services, and disproportionately high users of emergency services. The effect of new general practitioner (GP)-led urgent care centres in meeting the needs of adolescents are unknown. Methods We used routinely collected data to describe the demographics and attendance pattern among adolescents at two new colocated GP-led urgent care centres at Hammersmith and Charing Cross Hospitals, London. We also compared attendance rates with those observed in routine general practice and emergency departments. Results Adolescents formed 6.5% (N=14 038) of total urgent care attendances. 13.2% (95% CI 12.9% to 14.1%) was recorded as not being registered with a GP. Commonest reasons for attendance were musculoskeletal conditions and injuries (30.2%), respiratory tract infections (12.5%) and limb fractures (5.1%). Adolescents aged 15–19 years were more likely to attend the centres (30.6 vs 23.4, per 100, p<0.0001) than routine general practice. The opposite was true for adolescents aged 10–14 years. Conclusions Adolescents aged 15–19 years are more likely to attend urgent care centres than general practice. The majority attended for conditions commonly seen in primary care including musculoskeletal conditions and injuries, and respiratory tract infections. Primary care services may need to be more responsive to needs of the older adolescent age, if their use of urgent care centres is to be reduced.

Attendances at Charing Cross and Hammersmith Hospitals’ urgent care centres, 2009-12

Charing Cross and Hammersmith Hospitals’ accident and emergency services will be reconfigured under current plans.1 Both hospitals currently possess a GP led urgent care centre co-located with an emergency department; self referred patients are unable to access emergency departments without being seen by a GP or emergency nurse practitioner in an …