A Pharmacist Clinician Model as part of a collaborative clinical workforce: A philosophical critique.

The term 'clinician' is not reserved for any healthcare professional group. However, there is a general acceptance that a clinician would have the knowledge, skills and behaviours to enable them to clinically assess and manage a patient autonomously. The expectation, in a modern collaborative healthcare system, is that this work would be completed as a part of a planned and integrated multi-disciplinary care delivery structure, where any given clinician delivers a devolved element of that patient's care. Forthcoming changes to regulation and professional development pathways in the UK will have a profound impact on pharmacist professional identity and practice. From 2026, all new UK pharmacist registrants will have full independent prescribing rights. A paradigm shift is expected to enable the development of a Pharmacist Clinician Model, incorporating pharmaceutical care needs with wider clinical assessment, diagnostic, and clinical management responsibilities. Consideration is given to this model and its implications. Changes to regulation, policy, education, and the governance required to deliver safe and effective pharmacist clinicians are outlined. A philosophical critique on the nature of being a clinician, and the differentiation of pharmacist clinician roles compared to other healthcare professions, is given. A further examination of the projected risks and expected benefits of this transformative practice model are then explored.

Promoting excellence using a novel educational tool in the North of Scotland.

The General Medical Council (GMC) sets the standards and requirements for the delivery of all stages of medical education and training in the United Kingdom (UK). Using a novel educational tool (the 'Digital Carousel'), we set out to determine to what extent current systems and process sit alongside standards as set out in GMC document 'Promoting excellence' and establish key foci of work going forward to promote excellence in the Caledonian-Rural track (CRT) General Practice Specialty Training (GPST) educational programmes by engaging key stakeholders in the process. The 'Digital Carousel' allowed a large group of participants (including the Deanery team, GPSTs and ESs) to efficiently collaborate views on how our current GP training programme reflects guidance in 'Promoting excellence' and on areas for development. There was a sense of 'working together' in identifying key priorities of work for 'our' GP training programme. The tool may have value in a variety of medical educational settings.

Improving the primary-secondary care interface in Scotland: a qualitative exploration of impact on clinicians of an educational complex intervention.

OBJECTIVES: To determine the impact on clinicians and any consequent influence on patient care of taking part in the bespoke interface-focused educational intervention. DESIGN: Qualitative design. SETTING: Primary and secondary care centres in NHS Highland health board area, Scotland. PARTICIPANTS: 33 urban-based clinicians (18 general practitioners and 15 hospital specialists) in NHS Highland, Scotland. INTERVENTION: An interface-focused educational intervention was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians were invited to take part in the intervention which involved facilitated small group work, and use of a bespoke educational module. Subsequent one-to-one interviews explored the impact of the intervention. A standard thematic analysis was used, comprising an iterative process based on grounded theory. RESULTS: Key themes that emerged included fresh insights (in relation to those individuals and processes across the interface), adoption of new behaviours (eg, being more empowered to directly contact a colleague, taking steps to reduce the others workload and changes in professional approach) and changes in terms of communication (including a desire to communicate more effectively, with use of different modes and methods). CONCLUSION: The study highlighted key areas that may serve as useful outcomes for a large-scale randomised trial. Addressing issues identified in the study may help to improve interface relationships and benefit patient care.

Development of an interface-focused educational complex intervention.

BACKGROUND: In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients. AIM: To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions. METHODS: A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A 'meeting of experts' shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas. FINDINGS: The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention.

Unexpected deaths in cardiology outpatients - what can we learn from case review?

OBJECTIVES: A proportion of cardiac patients managed at a cardiology outpatient clinic will die between clinic visits. This study aimed to identify the cause of death, to determine if case review occurred and if a formal review of such cases might be useful. DESIGN: Single-centre retrospective cohort study. SETTING: A remote regional centre in the North of Scotland. PARTICIPANTS: All patients who had been removed from the cardiology outpatient clinic due to death in the community. MAIN OUTCOME MEASURES: Cause of death, comorbidities and treatments were collected from hospital records and the national register of deaths. Chi-squared test and Student's t-test were used with significance taken at the 5% level. RESULTS: Of 10,606 patients who attended the cardiology outpatient clinic, 75 (0.7%) patients died in the community. The majority (57.0%) died from a non-cardiac cause. Eleven patients (14.9%) died due to an unexpected cardiac death. A detailed case note review was undertaken. In only two (18.2%) cases was any note made as to the cause of death in the hospital records and in only one was there details of post mortem discussion between primary and secondary care. CONCLUSIONS: A small proportion of patients attending a cardiology outpatient clinic died in the community. Documentation of the death in the hospital notes was very poor and evidence of post mortem communication between primary and secondary care was absent in all but one case. Better documentation and communication between primary and secondary care would seem desirable.

Email communication at the medical primary-secondary care interface: a qualitative exploration.

BACKGROUND: There is little published research into the influence of email communication between primary and secondary care clinicians on patient care. AIM: To explore the use of email communication between clinicians across the primary- secondary care interface, and how this may relate to patient care. DESIGN AND SETTING: A qualitative study involving primary and secondary care services in the NHS Highland Health Board area, Scotland. Ten GPs and 12 hospital consultants were purposively sampled to reflect diversity. METHOD: Eligible clinicians were invited to take part in a semi-structured interview. Data were analysed using a thematic analysis approach. RESULTS: Key themes that emerged for clinicians included general perceptions of email; using email in practice (managing workload, impact on patient journeys, and 'quick answers'); system issues (variability and governance); relational aspects; and email skills. CONCLUSION: Email communication between primary and secondary care clinicians generally has a positive impact on patient access to specialist expertise. Governance issues around the use of clinical email need to be defined. There may currently be a two-tier health service for those patients (and their GPs) requiring 'quick answers'.

The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study.

BACKGROUND: Improving the quality of care of at the medical primary-secondary care interface is both a national and a wider concern. In a qualitative exploration of clinicians' relationship at the interface, we want to study how both GPs and hospital specialists regard and behave towards each other and how this may influence patient care. METHOD: A qualitative interview study was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians (general practitioners and hospital specialists) were invited to take part in a semi-structured interview to explore the implications of interface relationships upon patient care. A standard thematic analysis was used, involving an iterative process based on grounded theory. RESULTS: Key themes that emerged for clinicians included communication (the importance of accessing and listening to one another, and the transfer of soft intelligence), conduct (referring to perceived inappropriate transfer of workload at the interface, and resistance to this transfer), relationships (between interface clinicians and between clinicians and their patients), and unrealistic expectations (clinicians expressing idealistic hopes of what their colleagues at the other interface could achieve). CONCLUSION: The relationship between primary and secondary care clinicians, and, in particular, difficulties and misunderstandings can have an influence upon patient care. Addressing key areas identified in the study may help to improve interface relationships and benefit patient care.

Patients' perspectives on the medical primary-secondary care interface: systematic review and synthesis of qualitative research.

OBJECTIVES: To synthesise the published literature on the patient experience of the medical primary-secondary care interface and to determine priorities for future work in this field aimed at improving clinical outcomes. DESIGN: Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore patients' perspectives of the medical primary-secondary care interface. SETTING: International primary-secondary care interface. DATA SOURCES: EMBASE, MEDLINE, CINAHL Plus with Full text, PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection, Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index, and grey literature. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were eligible for inclusion if they were full research papers employing qualitative methodology to explore patients' perspectives of the medical primary-secondary care interface. REVIEW METHODS: The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data. RESULTS: The search identified 690 articles, of which 39 were selected for full-text review. 20 articles were included in the systematic review that encompassed a total of 689 patients from 10 countries. 4 important areas specific to the primary-secondary care interface from the patients' perspective emerged: barriers to care, communication, coordination, and 'relationships and personal value'. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Patients should be the focus of any transfer of care between primary and secondary systems. From their perspective, areas for improvement may be classified into four domains that should usefully guide future work aimed at improving quality at this important interface. TRIAL REGISTRATION NUMBER: PROSPERO CRD42014009486.

Sharing control of appointment length with patients in general practice: a qualitative study.

BACKGROUND: There is little published research into the impact, on both doctor and patient, of handing over responsibility for choosing appointment length to the patient. AIM: To investigate what impact giving patients control of their appointment length has on the patient and doctor experience. DESIGN AND SETTING: A qualitative study in a single medical practice in Inverness, Scotland. METHOD: Eligible patients making a 'routine' appointment were given a choice of appointment length (5, 10, 15, or 20 minutes). After the consultation, patients were invited to take part in a focused interview. Doctors were asked to keep an audio diary and their experience was explored further in a facilitated focus group. Data were analysed using a thematic analysis approach. RESULTS: Key themes that emerged for patients included the impact of the shift in power and the impact of introducing the issue of time. For doctors, important themes that emerged were impacts on the provider, on the doctor-patient relationship, and on the consultation. CONCLUSION: Giving patients greater responsibility for choosing appointment length may improve the experience for both doctors and patients.

Parental reasons for non-uptake of influenza vaccination in young at-risk groups: a qualitative study.

BACKGROUND: Uptake rates of influenza vaccination in young at-risk groups in primary care (UK) are known to be poor. AIM: To explore parental reasons for non-uptake of influenza vaccination in young at-risk groups. The study hypothesis was that exploration of parental reasons for non-uptake may reveal important barriers to an effective influenza vaccination programme. DESIGN AND SETTING: Thematic analysis of a questionnaire survey with interview follow-up at a single general practice in Inverness, Scotland. METHOD: Parents of children identified as being in an at-risk group for influenza vaccination but who had not received vaccination were sent questionnaires and offered the opportunity to take part in a follow-up interview. RESULTS: Several key themes emerged, including uncertainty about the indication for vaccination, issues of choice, challenges with access, lack of parental priority, and issues relating to health beliefs. CONCLUSION: Any attempt to improve the vaccination rate needs to address the range of decision-making processes undertaken by parents and children. Better and more tailored information and educational delivery to parents, patients, and healthcare providers may lead to an increase in the rates of influenza vaccination uptake in at-risk children. Access is a barrier described by some parents.