Publications
To provide effective, comprehensive care to increasingly complex patients in Canadian communities, healthcare providers are shifting from solo providers of primary care to interprofessional, team-based primary healthcare services. Team-based care is considered one of the most effective means of caring for complex patients, including frail elders and individuals with chronic illness, mental health issues and addictions. Team-based care relies on effective team processes, the social or relational processes that enhance team collaboration and decision making. This realist review will highlight the team processes associated with high-performing teams and provide team development and sustainment strategies for providers and healthcare decision makers.
Caring for people with dementia often necessitates inter-professional and inter-agency working but there is limited evidence of how home care staff work as a team and with professionals from different agencies. Through analysis of semi-structured interviews, we explored the experiences of home care workers (n = 30) and managers of home care services (n = 13) in England (2016?17). Both groups sought to collaboratively establish formal and informal practices of teamwork. Beyond the home care agency, experiences of interacting with the wider health and care workforce differed. More explicit encouragement of support for home care workers is needed by other professionals and their employers.
Pick-and-mix or 'portfolio' careers are increasingly popular in general practice and are a dominant strand of recruitment initiatives in the UK and Canada. Portfolio careers are frequently framed as GPs adopting roles outside of and in addition to general practice, for example, working in clinics or other organisations, offering subspecialist care. 'Portfolio GPs' are generally employed on a short-term or sessional contract basis, in contrast to 'partnership' or salaried employment models. Advertising 'variety' for new GPs appears sensible given worldwide workforce shortages and the promise of work?life balance from adaptable work hours. When asked about career intentions, medical students expressing interest in family medicine frequently add the caveat 'GP with a special interest'. Graduates are attracted to developing expertise in subspecialties and working in different contexts. Yet, in supporting career flexibility, we may in fact diminish the breadth of thinking as the cornerstone of general practice expertise and increase the vulnerability of GP careers. In this article, the authors reflect on the untoward clinical and educational consequences of 'pick-and-mix general practice' as a potentially counter-productive message capable of eroding the complex nature of general practice work.
Background
Social prescribing is a way of addressing the ?non-medical? needs (e.g. loneliness, debt, housing problems) that can affect people?s health and well-being. Connector schemes (e.g. delivered by care navigators or link workers) have become a key component to social prescribing?s delivery. Those in this role support patients by either (a) signposting them to relevant local assets (e.g. groups, organisations, charities, activities, events) or (b) taking time to assist them in identifying and prioritising their ?non-medical? needs and connecting them to relevant local assets. To understand how such connector schemes work, for whom, why and in what circumstances, we conducted a realist review.
Method
A search of electronic databases was supplemented with Google alerts and reference checking to locate grey literature. In addition, we sent a Freedom of Information request to all Clinical Commissioning Groups in England to identify any further evaluations of social prescribing connector schemes. Included studies were from the UK and focused on connector schemes for adult patients (18+ years) related to primary care.
Results
Our searches resulted in 118 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs). These CMOCs underpinned our emerging programme theory that centred on the essential role of ?buy-in? and connections. This was refined further by turning to existing theories on (a) social capital and (b) patient activation.
Conclusion
Our realist review highlights how connector roles, especially link workers, represent a vehicle for accruing social capital (e.g. trust, sense of belonging, practical support). We propose that this then gives patients the confidence, motivation, connections, knowledge and skills to manage their own well-being, thereby reducing their reliance on GPs. We also emphasise within the programme theory situations that could result in unintended consequences (e.g. increased demand on GPs).
With the recent publication of the NHS Long Term Plan and the renewal of the GP Contract, it is timely to consider what we value within general practice. In this article we consider normative ways of thinking about general practice and the implications for primary healthcare organisation and funding. We examine some of the opportunities and challenges that current 'common sense' thinking produces, shaping ways in which particular 'problems' and 'solutions' are constructed and accepted.3 We discuss potential 'gaps' or 'alternative' ways of thinking and their potential contribution to future policy and practice.
International governments, universities, and health and social care organisations celebrated the 40th anniversary of the Alma-Ata Declaration in October 2018. Alma-Ata1 was a landmark global commitment to primary health care (PHC), which conceptualised health, not only as provision of biomedical care, but also emphasised the importance of social and economic factors. This anniversary has been marked with the publication of the Astana Declaration in Kazakhstan 25?26 October 2018,2 which will contribute to events next year supporting ?universal health coverage? (UHC) and the 2030 Agenda for Sustainable Development Goals (SDG).
Professional boundaries may help care staff to clarify their role, manage risk and safeguard vulnerable clients. Yet there is a scarcity of evidence on how professional boundaries are negotiated in a non-clinical environment (e.g. the home) by the home-care workforce in the context of complex care needs (e.g. dementia, end-of-life care). Through analysis of semi-structured interviews, we investigated the experiences of home-care workers (N = 30) and their managers (N = 13) working for a range of home-care services in the South-East and London regions of England in 2016?17. Findings from this study indicate that home-care workers and their managers have clear perceptions of job role boundaries, yet these are modified in dementia care, particularly at end of life which routinely requires adaptability and flexibility. As a lone worker in a client's home, there may be challenges relating to safeguarding and risk to both clients and workers. The working environment exacerbates this, particularly during end-of-life care where emotional attachments to both clients and their family may affect the maintenance of professional boundaries. There is a need to adopt context-specific, flexible and inclusive attitudes to professional boundaries, which reconceptualise these to include relational care and atypical workplace conventions. Pre-set boundaries which safeguard clients and workers through psychological contracts may help to alleviate to some extent the pressure of the emotional labour undertaken by home-care workers.
Background
The experiences and beliefs of the home care workforce supporting people with dementia to live in their own homes up to the end of life have been relatively ignored in research.
Methods
This qualitative empirical study conducted in 2016, interviewed 28 home care workers and 12 managers from a range of home care agencies in South-East England and London. Framework analysis was conducted to identify themes or consistencies in the data.
Results
Preliminary findings suggest that blurred boundaries, the need for communication, the constant flux of a home care worker?s role and their perceptions of a client?s death were important factors in their work. This paper elaborates on the theme of ?perceptions of a client?s death?. This encompasses participants? experiences of a client?s death; the relevance of ?emotional labour? to explain the impact of their actions and reactions; and support in place to contextualise their experiences. Participants described close relationships with clients, at times resulting in strong attachments that made the process of grieving harder. A blurring of boundaries was reported regarding their role when the client?s death occurred, with some families wanting to be left alone, whilst current employment practices require the worker to stay in the home until professionals arrived. Moreover, home care workers were generally instructed not to touch the body, while some family requested assistance with cleaning, laying out, preparing or moving the body. Participants reported a range of sources of support, mainly from personal family and friends, and other colleagues. However, only a small proportion of staff reported being offered individual telephone support or group supervision to discuss work experiences. Many worked in isolation and felt there were few avenues for support from their employers.
Conclusions
Home care workers provide care to people with dementia at the end of life in isolation, with many experiencing lack of clarity in their caring role and limited support as their client nears the end of their life. Preliminary findings from this study may be helpful in developing support resources for home care practice and human resources management.
Context:
UK General Practice is being shaped by new ways of working with the release of both the NHS long-term plan and GP contract (BMA, 2019; NHS, 2019). Multidisciplinary teams and workforce expansion see the shifting, sharing, mixing and delegation of traditional GP tasks to other staff such as community paramedics. One of these tasks is the delegation of patient home visits in order to reduce both GP workload and hospital admissions. Yet the mechanisms of delegation (how and why delegation occurs) remain opaque and are likely to be highly dependent on a range of contexts.
Objective:
Our evidence synthesis explores the ways in which delegation of home visits relies upon context, which subsequently affects both patient outcomes and clinical workload within primary care settings.
Study Design:
Evidence is consolidated through a systematic realist review.
Dataset:
We have synthesised a range of relevant data including qualitative, quantitative, mixed-methods research and grey literature.
Population:
A total of 70 studies relating to primary care, with similar healthcare systems to the UK discussing delegation are included.
Outcome Measures:
A realist review produces context-mechanism-outcome configurations, which provide causal explanations.
Results:
Preliminary findings will be presented. Contexts such as the nature of employment, patient conditions and GP perspectives to delegation will be articulated. The impact on patient satisfaction and clinical workload will be discussed in relation to outcomes. Mechanisms such as risk tolerance and trust will be elucidated and the tensions between multi-disciplinary professional identities highlighted.
Expected Outcomes:
Our findings and causal explanations will produce review findings with potential to help future implementation of delegated home visits and provide guidance to support GP decision-making about how and when to delegate patient home visits.
Context:
Family Medicine is being challenged to articulate the nature of Generalist work. International challenges include: measurement, quality assurance and organisation of clinical work; and shaping of clinical curricula content. Organisation of care in the UK is shifting family medicine away from comprehensive negotiation of 'patient problems' towards specialised management of complexity and multi-morbidity. Consequences include an assumption that patients can problem-set and appropriately identify needs, alongside implications for healthcare workers? identities. In Canada, the increasing diversification of family physician roles, risks losing sight of what is core to generalist practice. It is therefore crucial to articulate the nature of 'Generalism' to sustain the legitimacy of family medicine and plan for workforce and capacity building alongside construction of relevant future education endeavours.
Objective:
To identify, synthesize and map concepts described in international research and policy literature that underpin 'Generalism'.
Study Design:
Scoping review Dataset: Systematic search of electronic databases (Pubmed, Psycinfo, OVID Healthstar, Scopus, Web of Science, ProQuest Dissertations). Inclusion of quantitative, qualitative, mixed-method studies, conceptual papers and grey literature, supplemented by citation searching and contact with primary authors. Search terms are being trialed iteratively. Exploded MeSH headings, database-specific controlled vocabulary and free text will be employed to ensure breadth and depth of coverage. Truncation and appropriate Boolean operators will be employed.
Population:
English-language studies, published in last 10 years in medicine (Family Medicine, internal medicine, paediatrics, psychiatry, surgery). Excluding: other health care professionals.
Outcome Measures:
Descriptive summaries (who is talking about generalism, where, definitions used), conceptual map of under-pinning principles and concepts of ?Generalism? (what); similarities and differences between contexts, disciplines; and identification of areas for future research.
Results:
Preliminary findings will be presented at a stakeholder meeting with in Nov, 2019.
Expected Outcomes:
Our findings will support colleagues to make explicit, support and sustain principles of Generalism in service and education future planning.
The inescapable presence of ageing is a subject that many of us may shy away from, perhaps in a bid to prolong youth, a wistful idea that confronts us visually in much of our media avenues today. Yet at some point we are likely to be faced with the fact that age is not a fad or fashion that will fade away. It is with this in mind that Pachana in her short introduction to ageing, endeavours to tackle the meanings and perceptions of ageing, along with the individual, cultural and societal implications of our assertions. In six concise chapters, Pachana takes her reader on a whirlwind tour of the history of ageing; the biological, psychological and interpersonal aspects of ageing; successful ageing and some well-considered reflections on where the nature of ageing will take us.
Introduction
In western countries, early visiting services (EVS) have been proposed as a recent intervention to reduce both general practitioner workload and hospital admissions among housebound individuals experiencing a healthcare need within the community. EVS involves the delegation of the patient home visits to other staff groups such as paramedics or nursing staff. However, the principles of organising this care are unknown and it remains unclear how different contexts, such as patient conditions and the processes of organising EVS influence care outcomes. A review has been designed to understand how EVS are enacted and, specifically, who benefits, why, how and when in order to provide further insight into the design and delivery of EVS.
Methods and analysis
The purpose of this review is to produce findings that provide explanations of how and why EVS contexts influence their associated outcomes. Evidence on EVS will be consolidated through realist review?a theory-driven approach to evidence synthesis. A realist approach is needed as EVS is a complex intervention. What EVS achieve is likely to vary for different individuals and contexts. We expect to synthesise a range of relevant data such as qualitative, quantitative and mixed-method research in the following stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesising and refining the programme theory.
This systematic review of the literature explores the perspectives and experiences of homecare workers providing care for people with dementia living at home up to the end of life. A search of major English language databases in 2016 identified 378 studies on the topic, of which 12 met the inclusion criteria. No empirical research was identified that specifically addressed the research question. However, synthesis of the findings from the broader literature revealed three overarching themes: value of job role, emotional labour and poor information and communication. The role of homecare workers supporting a person with dementia up to the end of life remains under-researched, with unmet needs for informational, technical and emotional support reported. The effective components of training and support are yet to be identified.
Home care workers provide practical care
and support to many older people with
dementia at home. They are the largest
dementia care workforce. The personal and
practical care they provide to older people
may continue until they die (even if other
professionals are involved). However, the
role, experiences, beliefs and attitudes of
home care workers providing care up to
the end of life for people with dementia
are often overlooked. There are limited
numbers of studies that have addressed
specifically how home care workers define
and manage possible conflict, stress and
competing demands; and these are hard
to distinguish from research on other
practitioners or covering settings outside
the home. This 18 month qualitative, exploratory study began with a review of
existing research evidence. Using systematic
methods, we identified research covering
home care, dementia and end of life. We
searched key databases and data sources
using relevant search terms, and reviewed
the evidence by identifying themes in the
papers and documents located, including
NICE guidelines on home care and on
end of life. This paper reports the findings
of the review and the ways the evidence
was used to inform fieldwork, including
drawing on advice from the research
advisory group in which older people and
carers actively participated.
The study investigated the experiences of home care workers and managers supporting people with dementia to live in their own homes up to the end of life. The presentation will specifically elaborate on the theme of ?perceptions of a client?s death?, which includes home care workers? experiences of the death, the relevance of ?emotional labour? in their actions and reactions, and the support available to them.
Extant selection and assessment literature predominantly utilises quantitative methodology and hypothetical job rejection
scenarios to assess candidate rejection experiences following face-to-face interviews. This often overlooks more nuanced, lived
experiences of real job seekers facing multiple rejections, reflective of current labour market turbulence. Informed by Karl Weick?s
(1995) organisational sense-making approach, the present study sought to explore the subjective feelings and sense-making processes
of actual job applicants. Using semi-structured interviews and Interpretative Phenomenological Analysis (IPA), the experiences of 10
active job seekers (rejected on 2-5 consecutive occasions following face-to-face interviews) were investigated. The effects of
cumulative rejections on job seekers? sense of identity and how they manage to make sense of these rejections was examined.
Findings suggest that cumulative job rejections negatively affect social identity and feelings of self-worth, especially when sensemaking is hindered by a lack of, or inappropriate, feedback. Where constructive and job relevant feedback is delivered by an
interview panel member, the rejected applicant is better able to make sense of the rejection in a way that supports self-efficacy and
personal identity. IPA as a methodology is limited by its small sample size and therefore findings are not generalizable. Extending the
preliminary findings from the present study to a range of assessment domains, with larger sample sizes, is now recommended. The
importance of applying findings from across research fields to inform best practice in assessment and selection (e.g. to avoid
undermining individual identity and esteem) is emphasised.
There is a lack of evidence on the experiences of
the home care workforce on providing care up
to the end of life for older people with dementia.
Taking an inductive approach, this empirical
study explored the subjective experiences and
challenges facing the home care workforce caring
for people with dementia, up to the end of life.
Using semi-structured interviews and Framework
Analysis, the experiences of 28 home care workers
and their managers (n=12) were investigated
in 2016 in a range of home care services in the
South-East and London regions of England. The
findings suggest that blurred boundaries, the
need for communication, the constant flux of a
home care worker?s role and their perceptions of
a client?s death were important factors in their
work. This paper elaborates on the theme of
blurred boundaries. The nature of this work may
result in personal attachments being formed with
older clients and families beyond professional
relationship. Many participants described
experiencing a conflict between completing a task
in the allocated time, alongside having the time to
provide relationship-centred care to older people
and often their spouses. Operating as a lone
worker in situations of potential stress and distress
creates environments where rigid employment
relationships are hard to sustain. From the
managers? perspective, cultural boundaries and
the role of the supervisor in helping maintain
boundaries at a distance are explored. The
importance of applying these findings to home
care practice and human resources management
will be discussed.
Problem
Recent policies including the NHS long term plan (NHS, 2019) and
the new GP contract (BMA, 2019) have re-shaped ways of working in
General Practice. In particular, multidisciplinary teams and workforce
expansion are seeing the shifting, sharing, mixing and delegation
of traditional GP tasks to other staff groups such as community
paramedics. One of these tasks is the delegation of patient home visits
in order to reduce both GP workload and hospital admissions. Yet the
mechanisms of delegation (i.e. how and why delegation occurs) remain
opaque and are likely to be highly dependent on a range of contexts.
Our synthesis of published evidence aims to explore the ways in which
delegation of a home visit relies on context which subsequently affects
both patient outcomes and clinical workload within primary care
settings.
Approach
Using a realist approach we have synthesised a range of data including
qualitative, quantitative and mixed-methods research in addition to
grey literature. We have followed the systematic realist review stages
advocated by Pawson, making visible the causal explanations of
contexts and mechanisms in relation to outcomes regarding delegated
home visits through our programme theory.
Findings
Contexts such as the nature of employment, patient conditions and
GP perspectives to delegation will be articulated. The impact on
patient satisfaction and clinical workload will be discussed in relation
to outcomes. Mechanisms such as risk tolerance and trust will be
elucidated and the tensions between multi-disciplinary professional
identities will be highlighted.
Consequences
Our findings and causal explanations are anticipated to produce review
findings that may help with future implementation of delegated home
visits and provide guidance to support GP decision-making to delegate
home visits to patients (or not).
In a recent expose called ?GPs: Why Can?t I Get an Appointment??, a Panorama documentary, which aired on BBC1 on Wednesday 8th May, emphasised the current limits of and pressures on the NHS system. The programme featured interviews with overworked GPs and allied healthcare professionals, painting a rather bleak picture. Practices are merging and closing at an ever increasing rate. Patient loads increase as patient lists are subsumed. Patient multi-morbidities have increased the need for chronic conditions to be monitored with regular GP appointments. Yet on average patients wait a minimum of two weeks for a routine appointment. Early retirement and a limited flow of trainees into General Practice also contribute to the strain, making practice sustainability difficult to envisage. Inevitably, pressure and frustration are being felt amongst both patient groups and the primary care workforce.
In this blog, we reflect on our attempts to seek information from Clinical Commissioning Groups (CCGs) in England, using freedom of information (FOI) requests, to contribute to our development of two realist reviews we are working on.
On Wednesday 23rd October, Sophie Park and Ruth Abrams, (researchers based within UCL?s Primary Care and Population Health department), in collaboration with the Menagerie Theatre Company opened the doors to Bloomsbury Theatre to introduce, ?Is there a doctor in the house? A performance and theatre workshop?. This event was a unique theatre experience, following the journey of a patient and carer as they navigated the twists and turns of our healthcare system.
The purpose of our event was to discuss, with healthcare practitioners, patients, students and the general public, the three important issues identified in our evidence synthesis on delegated home visits within primary care. This research was funded by the School for Primary Care Research as part of a bigger collaborative project on evidence synthesis, the evidence synthesis working group. Our findings suggest that (1) whilst patients report short-term satisfaction when visited by an alternative health professional, the impact this has on their health (and long-term outcomes) is less clear; (2) a GP may feel home visit delegation is a risky option unless they have high levels of trust and experience with the wider multidisciplinary team; and (3) the healthcare professional receiving the delegated home visit may benefit from being integrated into general practice. In the longer-term however, these posts may not be sustainable if staff feel their clinical autonomy is limited by the delegation process.
Today, patient and public involvement (PPI) in research activities ? as contributors rather than participants ? is an expected component of health-related studies [1]. Researchers are increasingly held to account for facilitating such involvement and for reporting it accurately in papers they write [2-3]. PPI has become commonplace in empirical, primary research, but it is less readily adopted within evidence synthesis. Evidence synthesis, an umbrella term for different approaches to combining existing literature, includes realist reviews. Realist reviews intend to explore what works, for whom and in what contexts, most commonly for a specific healthcare intervention or innovation [4]. Involving patients and the public within realist reviews has received much less attention than for other forms of evidence synthesis [5-6]. Having recently conducted a number of realist reviews, we reflected on PPI within these pieces of research. Two broad and important issues emerged - why are patient and public contributors being involved and how? We recognised that the need for and purpose of PPI differed between our reviews, as did the processes for involvement. Looking back across our reviews, we have generated the following prompts for researchers (see table 1) that would have been helpful to consider prior to the start of our realist reviews. These prompts have been iteratively developed by the research team with the help from two patient contributors involved in our reviews. We intend for these prompts to act as points of reflection for researchers doing realist reviews. These prompts remind researchers to clarify why and how they will involve patient and public contributors.
Last month, GPs in England voted to reduce home visits as part of their core contractual activities. The argument for this removal was cited as a lack of capacity amongst GPs to undertake home visits amid increasingly demanding workloads. These results were met with some opposition, but the vote means that the British Medical Association (BMA) will now lobby NHS England to revise the core services provided by GPs. However, the impact of this decision on both patient care and the wider workforce remains unclear.
Background:
UK general practice is being shaped by new
ways of working. Traditional GP tasks are
being delegated to other staff with the intention
of reducing GPs? workload and hospital
admissions, and improving patients? access
to care. One such task is patient-requested
home visits. However, it is unclear what impact
delegated home visits may have, who might
benefit, and under what circumstances.
Aim:
To explore how the process of delegating home
visits works, for whom, and in what contexts.
Design and setting
A review of secondary data on home visit
delegation processes in UK primary care
settings.
Method
A realist approach was taken to reviewing data,
which aims to provide causal explanations
through the generation and articulation of
contexts, mechanisms, and outcomes. A range
of data has been used including news items,
grey literature, and academic articles.
Results:
Data were synthesised from 70 documents.
GPs may believe that delegating home visits
is a risky option unless they have trust and
experience with the wider multidisciplinary
team. Internal systems such as technological
infrastructure might help or hinder the
delegation process. Healthcare professionals
carrying out delegated home visits might
benefit from being integrated into general
practice but may feel that their clinical
autonomy is limited by the delegation process.
Patients report short-term satisfaction when
visited by a healthcare professional other than
a GP. The impact this has on long-term health
outcomes and cost is less clear.
Conclusion:
The delegation of home visits may require a shift
in patient expectation about who undertakes
care. Professional expectations may also require
a shift, having implications for the balance of
staffing between primary and secondary care,
and the training of healthcare professionals.
Background: The demanding environment at medical school results in some students being prone to a high risk of mental health issues. GMC recommendations include positioning personal tutors for pastoral support and to act as academic role models. Tutors who are clinicians, such as GPs, could help students develop their academic and professional narratives. Our study explores interactions between GP tutors and students and evaluates how personal tutoring can support the ways in which students respond to the medical school culture and its demands.
Method: Six pairs of GP tutors and medical students had three personal tutor meetings over 9 months. Twelve meetings were recorded. A dialogical narrative analytical approach was used to assess how students? problems and reflective processes were negotiated with tutors. Three themes were formed to consolidate findings.
Results: Tutors? affirmations helped students develop an alternative narrative to perfectionism focusing on ?doing well? and self-care. Reflection on students? perceptions of a medical career were prompted by tutors who encouraged students to keep an open-minded and enthusiastic outlook. Active participation from students sometimes required tutors to relinquish hierarchical power and share personal experiences.
Conclusion: GP tutors can help reframe student narratives of perfectionism and professionalism by expressing their vulnerabilities and working collaboratively. With clear guidance, there is potential for personal tutors working as GPs, to benefit students in the long run both academically and professionally. However, this should go hand in hand with a transformation of medical school culture to prevent sole focus on building student resilience.
