Suicidal Thoughts and Behaviors in Parents Caring for Children with Disabilities and Long-Term Illnesses.

OBJECTIVE: There is a growing body of evidence on suicide risk in family carers, but minimal research on parents caring for children with disabilities and long-term illnesses. The aim of this study was to conduct the first dedicated research on suicide risk in parent carers and identify: (1) the number of parent carers experiencing suicidal thoughts and behaviors, and (2) the risk and protective factors for suicidality in this population. METHOD: A cross-sectional survey of parent carers in England (n = 750), co-produced with parent carers. Suicidal thoughts and behaviors were measured with questions from the Adult Psychiatric Morbidity Survey. Frequencies summarized the proportion of carers experiencing suicidal thoughts and behaviors. Logistic regressions identified risk and protective factors. RESULTS: 42% of parents had experienced suicidal thoughts and behaviors while caring for a disabled or chronically ill child. Only half had sought help for these experiences. Depression, entrapment, dysfunctional coping, and having a mental health diagnosis prior to caring, were significant risk factors. CONCLUSION: Parent carers contemplate suicide at levels that exceed those of other family carers and the general public. There is an urgent need, in policy and practice, to recognize parent carers as a priority group for prevention and intervention.

This is the first dedicated study of suicide risk in parent carers.More than 40% of parents had considered suicide while caring for a disabled or chronically ill child.The risk factors for suicidal ideation in parent carers were depression, entrapment, dysfunctional coping strategies, and having a mental health diagnosis prior to becoming a carer.Parent carers may be a high-risk group for suicide and need urgent support.

Suicidality in family caregivers of people with long-term illnesses and disabilities: A scoping review.

An emerging body of international research suggests family caregivers may be a high-risk group for suicide, but the evidence has not been synthesised. Forty-eight peer-reviewed journal articles were included in this review, spanning low-, middle-, and high-income countries and a variety of illnesses and disabilities. The proportion of caregivers experiencing suicidal ideation ranged from 2.7% to 71%, with evidence of suicide attempts, deaths by suicide, and deaths by homicide-suicide also reported. Risk and protective factors varied across studies and there was little consideration of differences by caregiving relationship, type of illness/disability, or country. There is sufficient evidence to warrant concern for caregivers around the world and prompt action in policy and practice, but more rigorous research is required to draw clear, nuanced conclusions about risk and inform evidence-based prevention and intervention.

Understanding why primary care doctors leave direct patient care: a systematic review of qualitative research.

BACKGROUND: UK general practitioners (GPs) are leaving direct patient care in significant numbers. We undertook a systematic review of qualitative research to identify factors affecting GPs' leaving behaviour in the workforce as part of a wider mixed methods study (ReGROUP). OBJECTIVE: To identify factors that affect GPs' decisions to leave direct patient care. METHODS: Qualitative interview-based studies were identified and their quality was assessed. A thematic analysis was performed and an explanatory model was constructed providing an overview of factors affecting UK GPs. Non-UK studies were considered separately. RESULTS: Six UK interview-based studies and one Australian interview-based study were identified. Three central dynamics that are key to understanding UK GP leaving behaviour were identified: factors associated with low job satisfaction, high job satisfaction and those linked to the doctor-patient relationship. The importance of contextual influence on job satisfaction emerged. GPs with high job satisfaction described feeling supported by good practice relationships, while GPs with poor job satisfaction described feeling overworked and unsupported with negatively impacted doctor-patient relationships. CONCLUSIONS: Many GPs report that job satisfaction directly relates to the quality of the doctor-patient relationship. Combined with changing relationships with patients and interfaces with secondary care, and the gradual sense of loss of autonomy within the workplace, many GPs report a reduction in job satisfaction. Once job satisfaction has become negatively impacted, the combined pressure of increased patient demand and workload, together with other stress factors, has left many feeling unsupported and vulnerable to burn-out and ill health, and ultimately to the decision to leave general practice.

Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained.

BACKGROUND: Ambitious overseas recruitment targets have been set by the UK government to help alleviate the current GP shortage. European Economic Area (EEA) doctors can join the UK's GP register under European law. Non-EEA doctors must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained doctors. CEGPR applications can be time-consuming and burdensome. To meet overseas recruitment targets, it is important to facilitate the most efficient route into UK general practice while maintaining registration standards and patient safety. AIM: To develop a methodology to map postgraduate GP training and healthcare contextual data from an overseas country to the UK. DESIGN & SETTING: Desk-based research and stakeholder interviews. METHOD: Four stages were undertaken: 1) developing a data collection template; 2) conducting a case study (using Australia as a test case); 3) refining the data collection template; and 4) creating a mapping framework. The case study used the 2016 curricula for the UK and Australia. RESULTS: Five 'domains' were identified: healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation. The final data collection template comprised 49 mapping items across the domains. The methodology incorporated the application of a red, amber, or green (RAG) rating to indicate similarity of data across the five domains. Australia was rated 'green' for training pathway, curriculum, and assessment, and 'amber' for healthcare context and CPD and revalidation. The overall rating was 'green'. CONCLUSION: Implementing this systematic methodology for mapping GP training between countries may support the UK's ambitions to recruit more GPs, and alleviate current GP workforce pressures.

Feasibility, acceptability and effectiveness of an online alternative to face-to-face consultation in general practice: a mixed-methods study of webGP in six Devon practices.

OBJECTIVES: To evaluate the feasibility, acceptability and effectiveness of webGP as piloted by six general practices. METHODS: Mixed-methods evaluation, including data extraction from practice databases, general practitioner (GP) completion of case reports, patient questionnaires and staff interviews. SETTING: General practices in NHS Northern, Eastern and Western Devon Clinical Commissioning Group's area approximately 6 months after implementing webGP (February-July 2016). PARTICIPANTS: Six practices provided consultations data; 20 GPs completed case reports (regarding 61 e-consults); 81 patients completed questionnaires; 5 GPs and 5 administrators were interviewed. OUTCOME MEASURES: Attitudes and experiences of practice staff and patients regarding webGP. RESULTS: WebGP uptake during the evaluation was small, showing no discernible impact on practice workload. The completeness of cross-sectional data on consultation workload varied between practices.GPs judged 41/61 (72%) of webGP requests to require a face-to-face or telephone consultation. Introducing webGP appeared to be associated with shifts in responsibility and workload between practice staff and between practices and patients.81/231 patients completed a postal survey (35.1% response rate). E-Consulters were somewhat younger and more likely to be employed than face-to-face respondents. WebGP appeared broadly acceptable to patients regarding timeliness and quality/experience of care provided. Similar problems were presented by all respondents. Both groups appeared equally familiar with other practice online services; e-consulters were somewhat more likely to have used them.From semistructured staff interviews, it appeared that, while largely acceptable within practice, introducing e-consults had potential for adverse interactions with pre-existing practice systems. CONCLUSIONS: There is potential to assess the impact of new systems on consultation patterns by extracting routine data from practice databases. Staff and patients noticed subtle changes to responsibilities associated with online options. Greater uptake requires good communication between practice and patients, and organisation of systems to avoid conflicts and misuse. Further research is required to evaluate the full potential of webGP in managing practice workload.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England.

OBJECTIVE: To identify factors influencing general practitioners' (GPs') decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role. DESIGN: Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care. SETTING: South West England, UK. PARTICIPANTS: 41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles. RESULTS: Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs' thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today's National Health Service for this group of GPs. CONCLUSION: Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs' perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs' concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care.

Pharmacists' perceptions of their emerging general practice roles in UK primary care: a qualitative interview study.

BACKGROUND: UK general practice is experiencing a workload crisis. Pharmacists are the third largest healthcare profession in the UK; however, their skills are a currently underutilised and potentially highly valuable resource for primary health care. This study forms part of the evaluation of an innovative training programme for pharmacists who are interested in extended roles in primary care, advocated by a UK collaborative '10-point GP workforce action plan'. AIM: To explore pharmacists' perceptions of primary care roles including the potential for greater integration of their profession into general practice. DESIGN AND SETTING: A qualitative interview study in UK primary care carried out between October 2015 and July 2016. METHOD: Pharmacists were purposively sampled by level of experience, geographical location, and type of workplace. Two confidential semi-structured telephone interviews were conducted - one before and one after the training programme. A constant comparative, inductive approach to thematic analysis was used. RESULTS: Sixteen participants were interviewed. The themes related to: initial expectations of the general practice role, varying by participants' experience of primary care; the influence of the training course with respect to managing uncertainty, critical appraisal skills, and confidence for the role; and predictions for the future of this role. CONCLUSION: There is enthusiasm and willingness among pharmacists for new, extended roles in primary care, which could effectively relieve GP workload pressures. A definition of the role, with examples of the knowledge, skills, and attributes required, should be made available to pharmacists, primary care teams, and the public. Training should include clinical skills teaching, set in context through exposure to general practice, and delivered motivationally by primary care practitioners.

Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners.

OBJECTIVE: Given recent concerns regarding general practitioner (GP) workforce capacity, we aimed to describe GPs' career intentions, especially those which might impact on GP workforce availability over the next 5 years. DESIGN: Census survey, conducted between April and June 2016 using postal and online responses , of all GPs on the National Health Service performers list and eligible to practise in primary care. Two reminders were used as necessary. SETTING: South West England (population 3.5 million), a region with low overall socioeconomic deprivation. PARTICIPANTS: Eligible GPs were 2248 out of 3370 (67 % response rate). MAIN OUTCOME MEASURES: Reported likelihood of permanently leaving or reducing hours spent in direct patient care or of taking a career break within the next 5 years and present morale weighted for non-response. RESULTS: Responders included 217 7 GPs engaged in patient care. Of these, 863 (37% weighted, 95% CI 35 % to 39 %) reported a high likelihood of quitting direct patient care within the next 5 years. Overall, 1535 (70% weighted, 95% CI 68 % to 72 %) respondents reported a career intention that would negatively impact GP workforce capacity over the next 5 years, through permanently leaving or reducing hours spent in direct patient care, or through taking a career break. GP age was an important predictor of career intentions; sharp increases in the proportion of GPs intending to quit patient care were evident from 52 years. Only 305 (14% weighted, 95% CI 13 % to 16 %) reported high morale, while 1195 ( 54 % weighted, 95% CI 52 % to 56 %) reported low morale. Low morale was particularly common among GP partners. Current morale strongly predicted GPs' career intentions; those with very low morale were particularly likely to report intentions to quit patient care or to take a career break. CONCLUSIONS: A substantial majority of GPs in South West England report low morale. Many are considering career intentions which, if implemented, would adversely impact GP workforce capacity within a short time period. STUDY REGISTRATION: NIHR HS&DR - 14/196/02, UKCRN ID 20700.

Understanding quit decisions in primary care: a qualitative study of older GPs.

OBJECTIVE: To investigate the reasons behind intentions to quit direct patient care among experienced general practitioners (GPs) aged 50-60 years. DESIGN AND SETTING: Qualitative study based on semistructured interviews with GPs in the South West region of England. Transcribed interviews were analysed thematically. PARTICIPANTS: 23 GPs aged 50-60 years: 3 who had retired from direct patient care before age 60, and 20 who intended to quit direct patient care within the next 5 years. RESULTS: The analysis identified four key themes: early retirement is a viable option for many GPs; GPs have employment options other than undertaking direct patient care; GPs report feeling they are doing an (almost) undoable job; and GPs may have other aspirations that pull them away from practice. Findings from this study confirmed those from earlier research, with high workload, ageing and health, family and domestic life, and organisational change all influencing GPs' decisions about when to retire/quit direct patient care. However, in addition, GPs expressed feelings of insecurity and uncertainty regarding the future of general practice, low morale, and issues regarding accountability (appraisal and revalidation) and governance. Suggestions about how to help retain GPs within the active clinical workforce were offered, covering individual, practice and organisational levels. CONCLUSIONS: This research highlights aspects of the current professional climate for GPs that are having an impact on retirement decisions. Any future changes to policy or practice to help retain experienced GPs will benefit from this informed understanding of GPs' views. Key factors to take into account include: making the GP workload more manageable; managing change sympathetically; paying attention to GPs' own health; improving confidence in the future of general practice; and improving GP morale.

Unstated factors in orthopaedic decision-making: a qualitative study.

BACKGROUND: Total joint replacement (TJR) of the hip or knee for osteoarthritis is among the most common elective surgical procedures. There is some inequity in provision of TJR. How decisions are made about who will have surgery may contribute to disparities in provision. The model of shared decision-making between patients and clinicians is advocated as an ideal by national bodies and guidelines. However, we do not know what happens within orthopaedic practice and whether this reflects the shared model. Our study examined how decisions are made about TJR in orthopaedic consultations. METHODS: The study used a qualitative research design comprising semi-structured interviews and observations. Participants were recruited from three hospital sites and provided their time free of charge. Seven clinicians involved in decision-making about TJR were approached to take part in the study, and six agreed to do so. Seventy-seven patients due to see these clinicians about TJR were approached to take part and 26 agreed to do so. The patients' outpatient appointments ('consultations') were observed and audio-recorded. Subsequent interviews with patients and clinicians examined decisions that were made at the appointments. Data were analysed using thematic analysis. RESULTS: Clinical and lifestyle factors were central components of the decision-making process. In addition, the roles that patients assigned to clinicians were key, as were communication styles. Patients saw clinicians as occupying expert roles and they deferred to clinicians' expertise. There was evidence that patients modified their behaviour within consultations to complement that of clinicians. Clinicians acknowledged the complexity of decision-making and provided descriptions of their own decision-making and communication styles. Patients and clinicians were aware of the use of clinical and lifestyle factors in decision-making and agreed in their description of clinicians' styles. Decisions were usually reached during consultations, but patients and clinicians sometimes said that treatment decisions had been made beforehand. Some patients expressed surprise about the decisions made in their consultations, but this did not necessarily imply dissatisfaction. CONCLUSIONS: The way in which roles and communication are played out in decision-making for TJR may affect the opportunity for shared decisions. This may contribute to variation in the provision of TJR. Making the importance of these factors explicit and highlighting the existence of patients' 'surprise' about consultation outcomes could empower patients within the decision-making process and enhance communication in orthopaedic consultations.

Routes to total joint replacement surgery: patients' and clinicians' perceptions of need.

OBJECTIVE: To explore patients' perspectives of need for total joint replacement associated with decision making in orthopaedic consultations for hip or knee osteoarthritis. METHODS: Twenty-six orthopaedic consultations in 3 UK hospitals were observed and audio recorded, and semistructured interviews were conducted with the involved patients and clinicians. Data were analyzed using thematic analysis. RESULTS: Two main routes to orthopaedic consultation were identified: patients who waited until their symptoms were no longer bearable (holding off), and patients who sought consultation preemptively (before it gets worse). These routes were mediated by age, comparison with others, demands and desires, deterioration, and convenience. Whether patients had held off or sought help preemptively influenced their perceptions of need. Patients' perceptions of their route to orthopaedic consultation, and consequently their perception of need, were either confirmed or contradicted by clinicians. CONCLUSION: When clinicians and patients have differing perceptions of need there may be ongoing patient anxiety, concern, and feelings of disempowerment. It is important for primary and secondary care clinicians to identify and explore a patient's perception of need in order to provide consistency in referral pathways and to support patient involvement in, and understanding of, shared decision making. Exploring the patient's perspective of their route to consultation is proposed as one easily achievable method of identifying patients' views on urgency of their need.