Estimated prevalence of people with learning disabilities: template for general practice.

BACKGROUND: In 2001, a white paper set out a commitment to ensure that people with a learning disability receive equal access to health services, with an expectation that general practices would have identified all people with a learning disability registered with the practice by June 2004. AIM: To outline the development of a template to create practice-based registers of people with learning disabilities in general practice. DESIGN OF STUDY: The study was prospective, employing a template to identify patients in general practice with a learning disability. The study used capture-recapture methodology to estimate the prevalence of learning disability in the population. SETTING: General practices in Leeds. METHOD: A template was developed that uses Read code searches of practices' electronic medical records, along with practice knowledge to identify patients who have a learning disability. RESULTS: The tool was piloted in 30 general practices in Leeds and validated against a city-wide database of people with learning disability. There was a wide variation between the practices in terms of how many people were identified, with the average being 0.4% of the practice population. Combined with validation from the city-wide database, this increased to 0.7%. CONCLUSION: The template provides a valuable tool for general practices to begin developing a practice-based register of patients with a learning disability. This is particularly timely in view of the revised General Medical Services contract Quality and Outcomes Framework indicator, stimulating practices to produce a register of patients with learning disability. Use of a common definition for learning disability is needed to improve consistency in identification across practices.

How do receptionists view continuity of care and access in general practice?

BACKGROUND: Continuity of care is widely regarded as an important feature of general practice, but the role of receptionists in influencing continuity has been the subject of little research. OBJECTIVE: To explore how receptionists might influence access and continuity of care in general practice. METHODS: A questionnaire survey of receptionists in practices in Leeds, UK, was conducted. All 119 practices in Leeds were contacted to recruit receptionists via practice managers. A total of 148 receptionists responded from 50 practices. RESULTS: The majority of receptionists (140, 94%) perceived continuity as team continuity. Most (139, 93%) felt it was important for the patient to be seen on the same day by any doctor, rather than the usual doctor. They were less willing to ask patients for more details of a routine problem than an urgent one. The majority (113, 76%) thought that non-attendance was more related to patient issues than to their own behaviour. Organizational factors affected how receptionists offered appointments. Advanced access could impede longitudinal continuity and, indirectly, relational continuity. Having a policy to deal with urgent appointments or routine appointments could facilitate such continuity. CONCLUSION: The majority of receptionists perceived continuity as a team response rather than longitudinal. However, if relational continuity is to survive in UK and European general practice, educational and training measures would need to be taken to promote these values to receptionists.

Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes.

BACKGROUND: Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance. AIM: This study aimed to compare outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis. DESIGN OF STUDY: Analysis of hospital records. SETTING: One hospital trust in England. METHOD: The records of 889 patients diagnosed in 2000-2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays. RESULTS: For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes (P = 0.035) and poorer survival (P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals. CONCLUSION: For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.

A new role for nurses as Primary Care Cancer Lead Clinicians in Primary Care Trusts in England.

AIM: The aim of this study was to evaluate the Primary Care Cancer Lead Clinician initiative in England. One of the objectives was to examine the impact of the Primary Care Cancer Lead Clinicians' clinical background on how they perform their role. This study compares nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. BACKGROUND: The Primary Care Cancer Lead Clinician initiative developed from the National Health Service Cancer Plan. Primary Care Cancer Lead Clinicians are expected to work strategically to raise the standards of cancer care within primary care. METHODS: A postal questionnaire survey was sent to Primary Care Cancer Lead Clinicians and one manager in each Primary Care Trust in England. Telephonic interviews were also undertaken with a range of stakeholders in six case study areas. RESULTS: There were striking similarities between nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. Differences related to the wider roles of the two groups. Nurses placed greater emphasis on fitting in whereas General Practitioners were more likely to expect to take charge and look for administrative support. CONCLUSIONS: There is evidence to show that whether the Primary Care Cancer Lead Clinician was a nurse or a General Practitioner was less important than having local credibility and the support of their Primary Care Trust.

Developing cancer services strategy in primary care in England: primary care trust managers' views of the primary care cancer leads initiative.

PURPOSE: Primary care cancer lead clinicians (PCCLs) act strategically in primary care trusts (PCTs) in England to improve communication and understanding of cancer across primary and secondary care and provide a link between Cancer Networks and primary care. The aim is to evaluate the first three years of the initiative. DESIGN/METHODOLOGY/APPROACH: A postal questionnaire was sent to all PCT chief executives in all PCTs in England and some were passed on to other PCT managers for completion. The response rate was 61 per cent. PCT directors of public health were the largest group of respondents (29 per cent). Most (74 per cent) PCCLs were GPs and 22 per cent were nurses. FINDINGS: PCCLs were most likely to focus on palliative care and preventive services. Key achievements were identified as raising awareness of cancer, developing relationships and promoting primary care. The personal skills of the PCCLs were important as was support of colleagues at all levels. Lack of time was a major barrier to achievement, as was a lack of understanding of the role from others. Links with the Cancer Networks were being developed. About 85 per cent of managers wanted the role to continue. ORIGINALITY/VALUE: The paper illustrates that PCCLs are at the forefront of improving cancer services in primary care. They are particularly important in view of the priority of reducing premature deaths and promotion of healthy lifestyles.

Patients' experiences of continuity in the care of type 2 diabetes: a focus group study in primary care.

BACKGROUND: Continuity of care is fundamental to general practice and type 2 diabetes is a common chronic disease with major health and social impacts. Nevertheless continuity, as experienced by patients with type 2 diabetes, remains a neglected area. AIM: To explore perceptions and experiences of continuity of care in general practice from the perspectives of patients with type 2 diabetes, focusing on the advantages and disadvantages of different types of continuity. DESIGN OF STUDY: Focus groups with patients. SETTING: Seven practices with different organisational structures in Leeds, UK. METHOD: Seventy-nine patients with type 2 diabetes were recruited. Focus group interviews were conducted with 79 patients with type 2 diabetes from seven practices in Leeds, UK. RESULTS: Patients experienced three different types of continuity: relational (or longitudinal) continuity, cross-boundary (or team) continuity, and continuity of information. Patients' perceptions of continuity were influenced by several factors including a personal relationship between themselves and their healthcare professional, their own beliefs and behaviours, presence of diabetes, and the systems and structures of general practices. Patients identified the advantages and disadvantages of two types of continuity. Relational or longitudinal continuity was important in providing psychosocial care, but with a risk of misdiagnosis. The advantages of cross-boundary or team continuity were to provide physical care, whereas the main disadvantages were the absence of personal care and patient confusion. CONCLUSION: Perceptions of continuity by patients with type 2 diabetes were influenced by several factors; they perceived several advantages and disadvantages associated with different types of continuity. Patients might expect certain healthcare benefits by following certain types of continuity.

Urgent GP referrals for suspected lung, colorectal, prostate and ovarian cancer.

BACKGROUND: The UK urgent cancer referral guidance was introduced between 1999-2000. There is a dearth of literature relating to the effectiveness in detecting cancer of urgent suspected cancer referrals and general practitioners' compliance with the guidance. AIMS: This paper aims to determine the diagnostic yield from urgent referrals for suspected colorectal, lung, ovarian and prostate cancer, and the proportion of patients with cancer who were urgently referred. Secondary aims are to determine the association of these findings with age, ethnicity, sex and marital status, and to determine the proportions of patients who fulfilled the urgent referral criteria. DESIGN: Detailed notes analysis of all urgent referrals and all cancer diagnoses. SETTING: One hospital trust in England. METHOD: Data regarding all urgent referrals and all cancer diagnoses were obtained from one hospital trust over a 2-year period. Data analysis was undertaken to determine, diagnostic yields and their association with sociodemographic factors, trends over time and fulfilment of the guidance. RESULTS: The percentages of urgent referrals diagnosed with cancer were colorectal 11%, lung 42%, ovarian 20%, and prostate 50%. The percentages of patients with cancer referred urgently were colorectal 21%, lung 23%, ovarian 24%, and prostate 32%. Patients who were urgently referred without cancer were younger than those with cancer for all but prostate. There were no significant differences by sex, marital status or ethnicity. For patients with cancer there were no differences for any sociodemographic factors in whether or not they were referred urgently. CONCLUSIONS: The predictive power of the referral guidance as a marker for cancer is low, resulting in significant numbers of patients being urgently referred without cancer. A large majority of patients not diagnosed with cancer through the urgent referral route did fulfil the criteria for urgent referral, suggesting that with more widespread use of the guidance the diagnostic yields will be higher. This has implications for patients, on hospital diagnostic systems, and for patients presenting through other pathways.

Quality monitoring of nurse telephone triage: pilot study.

BACKGROUND: Nurse telephone triage is a popular way of managing workload in primary care and has been shown to be as safe as general practitioner (GP)-delivered alternatives. No studies have tested a routine method of assessing the quality of decision-making by triage nurses in primary care. AIMS: The aim of this paper is to describe a study to evaluate accuracy and utility of audiotaping telephone consultations to assess the quality of decisions made by practice nurses triaging same day appointment requests in routine practice. METHOD: An observational study was carried out using external assessment by GPs and nurse practitioners of triage quality in 218 audiotaped nurse telephone triage consultations. RESULTS: There were high levels of agreement between triage nurses and assessors on identifying the presenting problem. However, there were only moderate levels of agreement between GPs and nurse assessors both on level of information sought (kappa = 0.434) and appropriateness of outcome (kappa = 0.614). Assessors rated information-gathering as poor in 19.3% of calls (95% confidence interval 14.6 to 25.0), and seven (3.2%) consultations were rated as potentially dangerous (95% confidence interval 1.6 to 6.5). A 1% sample of all consultations would have a probability of 0.48 of identifying unsafe consultations and 0.99 probability of identifying consultations with poor information-gathering. CONCLUSIONS: External assessment of triage quality may be of only moderate accuracy and reliability. Nonetheless, considerable information can be gleaned from assessing audiotapes to assess consultation quality. Even where nurses are generally highly skilled and competent, a 1% review of triage consultations would be sufficient to identify their information-gathering learning needs in relation to patients' presenting problems. Audio-taped consultations could be an important part of clinical governance strategies.

PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care.

BACKGROUND: Common mental health problems account for up to 40% of all general practitioner (GP) consultations. Patients have limited access to evidence-based psychological therapies. Cognitive behavioural therapy self-help strategies offer one potential solution. AIM: To determine differences in clinical outcome, patient satisfaction and costs, between a cognitive behavioural-based self-help package facilitated by practice nurses compared to ordinary care by GPs for mild to moderate anxiety and depression. DESIGN OF STUDY: Randomised controlled trial. SETTING: Seventeen primary healthcare teams. METHOD: Patients presenting to their GP with mild to moderate anxiety and/or depression were recruited to the study and randomised to receive either a self-help intervention facilitated by practice nurses or ordinary care. The self-help intervention consisted of up to three appointments: two 1 week apart and a third 3 months later. There were no restrictions on ordinary care. RESULTS: Intention-to-treat analysis showed that patients treated with practice nurse-supported cognitive behavioural therapy self-help attained similar clinical outcomes for similar costs and were more satisfied than patients treated by GPs with ordinary care. On-treatment analysis showed patients receiving the facilitated cognitive behavioural therapy self-help were more likely to be below clinical threshold at 1 month compared to the ordinary care group (odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.87 to 4.37). This difference was less well marked at 3 months (OR = 1.36, 95% CI = 0.52 to 3.56). CONCLUSION: Facilitated cognitive behavioural self-help may provide a short-term cost-effective clinical benefit for patients with mild to moderate anxiety and depression. This has the potential to help primary care provide a choice of effective psychological as well as pharmacological treatments for mental health problems.