Rural generalist medicine: a developing approach to health care in rural and island Japan.

INTRODUCTION: Despite universal health coverage and high life expectancy, Japan faces challenges in health care that include providing care for the world's oldest population, increasing healthcare costs, physician maldistribution and an entrenched medical workforce and training system. Primary health care has typically been practised by specialists in other fields, and general medicine has only been certified as an accredited specialty since 2018. There are continued challenges to develop an awareness and acceptance of the primary health medical workforce in Japan. The impact of these challenges is highest in rural and island areas of Japan, with nearly 50% of rural and remote populations considered 'elderly'. Concurrently, these areas are experiencing physician shortages as medical graduates gravitate to urban areas and choose medical specialties more commonly practised in cities. This study aimed to understand the views on the role of rural generalist medicine (RGM) in contributing to solutions for rural and island health care in Japan. METHODS: This was a descriptive qualitative study. Data were collected via semi-structured interviews with 16 participants, including Rural Generalist Program Japan (RGPJ) registrars and supervisors, the RGPJ director, government officials, rural health experts and academics. Interviews were of 35-50 minutes duration and conducted between May and July 2019. Some interviews were conducted in person at the WONCA Asia-Pacific Conference in Kyoto, some onsite in hospital settings and some were videoconferenced. Interviews were recorded and transcribed. All transcripts were analysed through an inductive thematic process based on the grouping of codes. RESULTS: From the interview analysis, six main themes were identified: (1) key issues facing rural and island health in Japan; (2) participant background; (3) local demography and population; (4) identity, perception and role of RGM; (5) RGPJ experience; and (6) suggested reforms and recommendations. DISCUSSION: The RGPJ was generally considered to be a positive step toward reshaping the medical workforce to address the geographic inequities in Japan. While improvements to the program were suggested by participants, it was also generally agreed that a more systematic, national approach to RGM was needed in Japan. Key findings from this study are relevant to this goal. This includes considering the drivers to participating in the RGPJ for future recruitment strategies and the need for an idiosyncratic Japanese model of RGM, with agreed advanced skills and supervision models. Also important are the issues raised by participants on the need to improve community acceptance and branding of rural generalist doctors to support primary care in rural and island areas. CONCLUSION: The RGPJ represents an effort to bolster the national rural medical workforce in Japan. Discussions from participants in this study indicate strong support to continue research, exploration and expansion of a national RGM model that is contextualised for Japanese conditions and that is branded and promoted to build community support for the role of the rural generalist.

[General practice and occupational medicine: a dynamic exchange?] / Médecine générale, médecine du travail : quelle dynamique d'échange ?

GENERAL PRACTICE AND OCCUPATIONAL MEDICINE: A DYNAMIC EXCHANGE? Occupational physicians and general practitioners have different roles but share the common goal of maintaining and promoting the health of the population. Their collaboration is necessary, and both practitioners and employees are generally in favor of it. This collaboration is particularly necessary in several situations: the discovery of a pathology by the occupational physician, the need for temporary incapacity, or difficulties in maintaining employment. Especially in the case of musculoskeletal disorders and mental suffering at work. The pre-reinstatement visit is an important tool for achieving this collaboration. There are also several ways of improving these exchanges, such as the introduction of joint training courses.

MÉDECINE GÉNÉRALE, MÉDECINE DU TRAVAIL : QUELLE DYNAMIQUE D'ÉCHANGE ? Le médecin du travail et le médecin généraliste ont des places et des rôles différents mais pour objectif commun de maintenir et promouvoir la santé de la population. Leur nécessaire collaboration, à laquelle les praticiens comme les salariés se disent globalement favorables, est pourtant insuffisamment constatée sur le terrain. Cette collaboration est nécessaire dans plusieurs situations : découverte d'une pathologie par le médecin du travail, nécessité d'une inaptitude temporaire ou encore difficultés de maintien en emploi. C'est particulièrement le cas pour les situations de troubles musculo-squelettiques et de souffrance psychique au travail. La visite de préreprise est un outil important pour permettre cette collaboration. Il existe également plusieurs pistes d'amélioration de ces échanges, comme la mise en place de formations communes.

Advancing integrated paediatric care in Australian general practices: Qualitative insights from the SC4C GP-paediatrician model of care.

The Strengthening Care for Children (SC4C) is a general practitioner (GP)-paediatrician integrated model of care that consists of co-consulting sessions and case discussions in the general practice setting, with email and telephone support provided by paediatricians to GPs during weekdays. This model was implemented in 21 general practices in Australia (11 Victoria and 10 New South Wales). Our study aimed to identify the factors moderating the implementation of SC4C from the perspectives of GPs, general practice personnel, paediatricians and families. We conducted a qualitative study as part of the mixed-methods implementation evaluation of the SC4C trial. We collected data through virtual and in-person focus groups at the general practices and phone, virtual and in-person interviews. Data was analysed using an iterative hybrid inductive-deductive thematic analysis. Twenty-one focus groups and thirty-seven interviews were conducted. Overall, participants found SC4C acceptable and suitable for general practices, with GPs willing to learn and expand their paediatric care role. GPs cited improved confidence and knowledge due to the model. Paediatricians reported an enhanced understanding of the general practice context and the strain under which GPs work. GPs and paediatricians reported that this model allowed them to build trust-based relationships with a common goal of improving care for children. Additionally, they felt some aspects, including the lack of remuneration and the work and effort required to deliver the model, need to be considered for the long-term success of the model. Families expressed their satisfaction with the shared knowledge and quality of care jointly delivered by GPs and paediatricians and highlighted that this model of care provides easy access to specialty services without out-of-pocket costs. Future research should focus on finding strategies to ensure the long-term Implementation of this model of care with a particular focus on the individual stressors in general practices.

Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals.

BACKGROUND: In recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. METHODS: This study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework. RESULTS: In total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member). CONCLUSION: The addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.

Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study.

BACKGROUND: People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care. AIM: To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work. DESIGN AND SETTING: The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices. METHOD: Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis. RESULTS: By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD. CONCLUSION: The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.

Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views.

BACKGROUND: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Exploring whether primary care networks can contribute to the national goal of reducing health inequalities: a mixed-methods study.

BACKGROUND: Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities. AIM: To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities. DESIGN AND SETTING: A sequential mixed-methods study of PCNs in England. METHOD: Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019-2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020-March 2022). RESULTS: Across 1243 networks in 2019-2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022-2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally. CONCLUSION: Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.

Implementing the Additional Roles Reimbursement Scheme in seven English Primary Care Networks: a qualitative study.

BACKGROUND: The Additional Roles Reimbursement Scheme (ARRS) provides funding to Primary Care Networks (PCNs) in England to recruit additional staff into specified roles. The intention was to support general practice by recruiting an extra 26 000 staff by 2024, increasing access and easing workload pressures. AIM: To explore the establishment of the ARRS as part of PCNs' development to understand their role in supporting general practice. DESIGN AND SETTING: A longitudinal, qualitative case study involving seven geographically dispersed PCNs across England. METHOD: Data were collected from July 2020 to March 2022, including 91 semi-structured interviews and 87 h of meeting observations. Transcripts were analysed using the framework approach. RESULTS: Implementation of the ARRS was variable across the study sites, but most shared similar experiences and concerns. The COVID-19 pandemic had a significant impact on the introduction of the new roles, and significant variability was found in modes of employment. Cross-cutting issues included: the need for additional space to accommodate new staff; the inflexibility of aspects of the scheme, including reinvestment of unspent funds; and the need for support and oversight of employed staff. Perceived benefits of the ARRS include improved patient care and the potential to save GP time. CONCLUSION: The findings suggest the ARRS has potential to fulfil its objective of supporting and improving access to general practice. However, attention to operational requirements including appropriate funding, estates, and management of staff is important if this is to be realised, as is clarity for the scheme post-contract end in 2024.

Managing patient complaints to improve your practice.

BACKGROUND: Increasing numbers of patient complaints to regulators suggest practices need effective systems to manage and address patient concerns. Many patient complaints can often be dealt with at a practice level, but patients can have difficulty reporting negative experiences directly. OBJECTIVE: This article explores the benefits of having a system to accept and deal with patient feedback within a practice and identifies barriers preventing patients from raising their concerns directly. DISCUSSION: Managing patient complaints well at a practice level can prevent them escalating, as well as offering insights to reduce risk and improve patient care. Understanding factors that inhibit patients from raising concerns, or prevent staff from being able to accept and deal with complaints, allows an opportunity for practices to implement strategies to address these barriers and support patients and staff. Effective strategies include process improvements, as well as cultural changes and support for those managing a complaint process.

How do multi-morbidity and polypharmacy affect general practice attendance and referral rates? A retrospective analysis of consultations.

BACKGROUND: As prevalence of multimorbidity and polypharmacy rise, health care systems must respond to these challenges. Data is needed from general practice regarding the impact of age, number of chronic illnesses and medications on specific metrics of healthcare utilisation. METHODS: This was a retrospective study of general practices in a university-affiliated education and research network, consisting of 72 practices. Records from a random sample of 100 patients aged 50 years and over who attended each participating practice in the previous two years were analysed. Through manual record searching, data were collected on patient demographics, number of chronic illnesses and medications, numbers of attendances to the general practitioner (GP), practice nurse, home visits and referrals to a hospital doctor. Attendance and referral rates were expressed per person-years for each demographic variable and the ratio of attendance to referral rate was also calculated. RESULTS: Of the 72 practices invited to participate, 68 (94%) accepted, providing complete data on a total of 6603 patients' records and 89,667 consultations with the GP or practice nurse; 50.1% of patients had been referred to hospital in the previous two years. The attendance rate to general practice was 4.94 per person per year and the referral rate to the hospital was 0.6 per person per year, giving a ratio of over eight attendances for every referral. Increasing age, number of chronic illnesses and number of medications were associated with increased attendance rates to the GP and practice nurse and home visits but did not significantly increase the ratio of attendance to referral rate. DISCUSSION: As age, morbidity and number of medications rise, so too do all types of consultations in general practice. However, the rate of referral remains relatively stable. General practice must be supported to provide person centred care to an ageing population with rising rates of multi-morbidity and polypharmacy.

'Here to stay': changes to prescribing medication in general practice during the COVID-19 pandemic in New Zealand.

INTRODUCTION The delivery of health care by primary care general practices rapidly changed in response to the coronavirus disease 2019 (COVID-19) pandemic in early 2020. AIM This study explores the experience of a large group of New Zealand general practice health-care professionals with changes to prescribing medication during the COVID-19 pandemic. METHODS We qualitatively analysed a subtheme on prescribing medication from the General Practice Pandemic Experience New Zealand (GPPENZ) study, where general practice team members nationwide were invited to participate in five surveys over 16 weeks from 8 May 2020. RESULTS Overall, 78 (48%) of 164 participants enrolled in the study completed all surveys. Five themes were identified: changes to prescribing medicines; benefits of electronic prescription; technical challenges; clinical and medication supply challenges; and opportunities for the future. There was a rapid adoption of electronic prescribing as an adjunct to use of telehealth, minimising in-person consultations and paper prescription handling. Many found electronic prescribing an efficient and streamlined processes, whereas others had technical barriers and transmission to pharmacies was unreliable with sometimes incompatible systems. There was initially increased demand for repeat medications, and at the same time, concern that vulnerable patients did not have usual access to medication. The benefits of innovation at a time of crisis were recognised and respondents were optimistic that e-prescribing technical challenges could be resolved. DISCUSSION Improving e-prescribing technology between prescribers and dispensers, initiatives to maintain access to medication, particularly for vulnerable populations, and permanent regulatory changes will help patients continue to access their medications through future pandemic disruption.