Recent Submissions

  • Impact of a dietitian in general practice: Paediatric food allergy

    Freeman-Hughes, Amy (2022)
    BACKGROUND: Food allergy in infants and young children places a significant burden on primary care. This study evaluated a dietetic-led paediatric food allergy service, which attempts to provide more rapid access to the dietitian and reduce the need for general practitioner (GP) and secondary care appointments. METHOD(S): Two community dietetic services for children referred with food allergy were compared. The first was dietetic-led care where dietitians train community children's nurses to recognise potential cases of food allergy, undertake basic diagnostic assessment and subsequently refer to the dietitian. The other is a more traditional dietetic community service where patients are referred predominantly by the GP or secondary care. RESULT(S): In dietetic-led care 86 patients were seen, compared to 96 in dietetic community care. Dietetic-led care received less referrals from the GP; 36% vs 67% (p<0.001), GP appointments for allergy-related conditions prior to dietetic referral were lower; 3 vs 6 visits (p=0.001) and input from secondary care was also lower; 8 vs 25 patients (p=0.002) compared with dietetic community care. Children referred to dietetic-led care were younger; 78% <6 months vs 40% (p<0.001) in dietetic community care. CONCLUSION(S): Dietetic-led care describes a model that has the potential to reduce GP and secondary care appointments, identify patients more quickly and reduce the time to receive dietetic input, thereby resolving symptoms more quickly and reducing prescribed medications. This model demonstrates the importance of integrated care and multidisciplinary working; offering a solution to reducing GP workload whilst maintaining or improving patient care. This article is protected by copyright. All rights reserved.
  • Evaluation of a web-based ADHD awareness training in primary care: Pilot randomized controlled trial with nested interviews

    French, Blandine; Hall, Charlotte L.; Perez Vallejos, Elvira; Sayal, Kapil; Daley, David (2020)
    BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting up to 5% of children and adults. Undiagnosed and untreated ADHD can result in adverse long-term health, educational, and social impacts for affected individuals. Therefore, it is important to identify this disorder as early as possible. General practitioners (GPs) frequently play a gatekeeper role in access to specialist services in charge of diagnosis and treatment. Studies have shown that their lack of knowledge and understanding about ADHD can create barriers to care. OBJECTIVE: This pilot randomized controlled trial assesses the efficacy of a web-based psychoeducation program on ADHD tailored for GPs. METHODS: A total of 221 participants were randomized to either a sham intervention control or an awareness training intervention and they completed questionnaires on ADHD knowledge, confidence, and attitude at 3 time points (preintervention, postintervention, and 2-week follow-up). Participants in the intervention arm were invited to participate in a survey and follow-up interview between 3 and 6 months after the intervention. RESULTS: The responses of 109 GPs were included in the analysis. The knowledge (P<.001) and confidence (P<.001) of the GPs increased after the intervention, whereas misconceptions decreased (P=.04); this was maintained at the 2-week follow-up (knowledge, P<.001; confidence, P<.001; misconceptions, P=.03). Interviews and surveys also confirmed a change in practice over time. CONCLUSIONS: These findings demonstrate that a short web-based intervention can increase GPs' understanding, attitude, and practice toward ADHD, potentially improving patients' access to care. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number ISRCTN45400501;
  • Development and evaluation of an online education tool on attention deficit hyperactivity disorder for general practitioners: the important contribution of co-production

    French, Blandine; Daley, David; Perez Vallejos, Elvira; Sayal, Kapil; Hall, Charlotte L. (2020)
    Background: Attention deficit hyperactivity disorder (ADHD) is underdiagnosed in the UK and the assessment and diagnosis pathway often involves a general practitioner (GP) referral to secondary care services. GPs’ levels of knowledge and understanding about ADHD is often a significant barrier in patients accessing care. The development of an online education resource could improve GPs knowledge of ADHD and optimise appropriate referrals. Involving end-users in co-creating interventions may enhance their clinical utility and impact routine clinical practice. However, there is limited published evidence describing how to meaningfully involve stakeholders in both the design and development components of co-production. Method: We report a step wise, co-production approach towards developing an online ADHD education intervention for GPs. Preparatory work highlighted the relevant topics to be included in the intervention, from which educational videos were then developed. Workshops were then conducted with GPs, leading to further refinement of the video content and subsequently the final intervention. A pilot usability study (n = 10 GPs) was then conducted to assess the intervention’s acceptability, feasibility and accessibility. Results: The development of the online intervention was greatly facilitated by the involvement of GPs. Having a co-production development process ensured the consistent adaptation of the intervention to meet GPs’ needs. The usability study showed that the content of the intervention was suitable, easily accessible, engaging and delivered at an acceptable level of intensity, validating the development approach taken. Conclusion: While further studies are needed to evaluate the efficacy of the developed intervention, preliminary findings demonstrated that it was acceptable and well received. The importance of co-development was highlighted in developing an intervention that addresses specific needs for GPs. This development approach may be useful for other researchers and developers of clinical interventions.
  • Viewpoint: Exemplary collaboration with a GP and psychiatrist

    Mittal, Shweta (2019)
    It was a usual day for me going to visit a suicidal patient after booking a room at his GP’s practice. As a consultant psychiatrist in a crisis team, nearly all the patients on my caseload have suicidal ideation or have made an attempt to kill themselves [Continued in full text]
  • An electronic clinical decision support system for the assessment and management of suicidality in primary care: Protocol for a mixed-methods study

    Horrocks, Matthew; Aubeeluck, Aimee; Wright, Nicola; Morriss, Richard K. (2018)
    Background: Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management is an area that many General Practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalise and assess suicide risk which subsequently has an impact on clinical decision making. Clinical Decision Support systems (CDSS) have been widely implemented across different healthcare settings, including primary care to support practitioners in clinical decision making. CDSS may reduce inconsistencies in the identification, assessment and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialised mental health services. Objective: To co-develop and test with end users (e.g. GPs, primary care attendees, mental health professionals) an e-CDSS to support GPs in the identification, assessment and management of suicidality in primary care. Methods: An ongoing embedded mixed methods study with four phases: 1) Qualitative interviews with GPs to explore their views on the content, format and use of the e-CDSS; consultation with two service user advisory groups (people aged ≤ 25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; 2) Participatory co-production workshops with GPs, service users and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity (CVI) and identify pathways to implementation, using the Consolidated Framework for Implementation Research; 3) Building the e-CDSS so that it guides the GP through a consultation and 4) Usability testing of the e-CDSS with GPs and service users in one primary care practice involving a non-live and a live stage. Results: This is an ongoing study. The findings will enable us to evaluate the feasibility, acceptability and usability of a suicide specific electronic guided decision support system in primary care. Conclusions: This study will be the first to explore the feasibility, acceptability and usability of electronic guided decision support system for use in primary care consultations for the improved assessment and management of suicidality.
  • Recommendations to facilitate the ideal fit note: Are they achievable in practice?

    Thomson, Louise (2015)
    BACKGROUND: Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the 'ideal' fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders. METHODS: Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically. RESULTS: Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice. CONCLUSIONS: This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully.
  • How do GPS complete fit note comments?

    Thomson, Louise (2013)
    Background: The 'fit note' was introduced in the UK in April 2010, to facilitate return to work (RTW). However, no research to date has reported on how general practitioners (GPs) complete the comments section of the fit note. Aims: To investigate the content of GPs' comments in a sample of actual fit notes. Methods: Data were collected in a service evaluation of fit notes issued by a regular general practice and those issued by a fit for work service (FFWS), where the fit notes for patients using the service are signed by GPs who have completed or are studying for a Diploma in Occupational Medicine. Content analysis was conducted on the fit note comments. Results: There were 1212 fit notes available for analysis. Seven hundred and twelve were issued by the general practice and 500 by the FFWS. The FFWS made comments in 98% of those who may be fit and 90% of those not fit against 72% and 12%, respectively, for comments by the general practice. Fourteen different categories were identified in the comments. Most comments made some reference to RTW but few described the functional effects of the patient's condition. Comments frequently covered more than one category and appeared to be serving a number of different purposes. Conclusions: There was a wide variety in how the comments section was completed, and GPs were not completing the fit note as intended. The information provided may require improvement if it is to be useful to employers. © The Author 2013. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved.
  • A survey of General Practitioners' preferences, when referring to mental health services, and the implications for electronic-outpatient booking

    Harvey, N. S. (2005)
    Electronic outpatient booking is to be introduced in England by 31st December, 2005, as a government initiative to speed up access to secondary care. For psychiatry, general practitioners (GPs) will be able to send referrals electronically to a multi-disciplinary allocation meeting that provides outpatient appointments, re-routes referrals and offers advice. The referrals may be sent during patient consultations, and the date of the multidisciplinary meeting given to patients, along with details for ascertaining the outcome within 24 hours and, if agreed, making an outpatient appointment at a convenient time. At present, there is little information on how GPs choose from a growing number of alternatives to outpatient referral. We have used a questionnaire to assess GPs' preferences in prioritising and referring patients to a variety of services that operate in conjunction with psychiatry. The questionnaire was sent to 114 sector GPs in Sheffield. 107 (94%) responded. GP referral letters were then assessed for a year, and the questionnaire re-sent to determine test-re-test reliability. Eighty-two GPs (72%) responded to the second questionnaire. GPs reported referring to community psychiatric nurses (CPNs) "moderately often," (level 3 on a 4-point scale) and to psychiatrists only "occasionally" (level 2). Paranoid schizophrenia and depressive illness received medium priority, ie. would be seen within 3 days, compared with 24 hours for problems including physical violence within the family. Urgency of confused and suicidal patients was judged inconsistently, as was who should manage weight loss, nonorganic physical complaints, an anxiety attack, disclosure of sexual abuse, and physical violence in the family. GPs producing high quality psychiatric referral letters had graduated more recently (P < 0.0003) and referred more widely (P < 0.05) within the services available. Their tailored approach to patients' needs produced the most appropriate referrals, as judged by our multi-disciplinary allocation meeting. Such tailoring may be expected to benefit from updates on how services are evolving, and from information about alternative referral routes available across disciplines. This could potentially be provided by electronic booking systems, but those planned for England and Wales will not have the full range of psychiatric multi-agency referral pathways. Electronic booking has not been agreed in Scotland.
  • Polyclinics and psychiatry: Risks and opportunities

    Hampson, Michele (2010)
    The arrival of the 'polyclinic' or 'GP-led health centre' has been signalled in the review of the National Health Service. A variety of options have been proposed for the way in which polyclinics will incorporate specialist services to work alongside primary care, and the relevance of these models to mental healthcare is considered. Polyclinics provide new opportunities but with those possibilities come potential threats and risks. Of key importance is the threat that they will re-institutionalise mental healthcare after many years of breaking down such barriers. Buildings provide shared space, but new working practices are more difficult to achieve.
  • Audit of informed consent practice within a Community Mental Health Team

    O'Donovan, Rebecca; Schofield, Christopher (2011)
    The letters from a Community Mental Health Team to patients' general practitioners were reviewed to identify the standard of informed consent documentation. A tool was developed to achieve the expected standards for informed consent documentation and its effects on practice evaluated. Statistically significant improvements were shown using our tool in documentation of discussion of risks; increased by 36% (P ≤ 0.0017, CI 15-58%) benefits of the treatment plan, increased by 56% (P ≤ 0.010-4, CI 38-74%) risks and benefits of no treatment, increased by 52% (P ≤ 0.010-4, CI 33-71%); side-effects, increased by 25% (P ≤ 0.0298, CI 3-47%) and written material improved by 28% (P ≤ 0.0109, CI 7-48%). There are significant clinical implications for the results of this audit as informed consent is fundamental to good practice; this intervention is quick, simple and enables clinicians to demonstrate valid consent, protecting the patient and clinician.;