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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Narrative Based Medicine
Edited by two leading general practitioners and with contributions from over 20 authors, this book covers a wide range of topics to do with narrative in medicine.
Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine
Objective: To develop and validate an instrument for measuring knowledge and skills in evidence based medicine and to investigate whether short courses in evidence based medicine lead to a meaningful increase in knowledge and skills. Design: Development and validation of an assessment instrument and before and after study. Setting: Various postgraduate short courses in evidence based medicine in Germany. Participants: The instrument was validated with experts in evidence based medicine, postgraduate doctors, and medical students. The effect of courses was assessed by postgraduate doctors from medical and surgical backgrounds. Intervention: Intensive 3 day courses in evidence based medicine delivered through tutor facilitated small groups. Main outcome measure: Increase in knowledge and skills. Results: The questionnaire distinguished reliably between groups with different expertise in evidence based medicine. Experts attained a threefold higher average score than students. Postgraduates who had not attended a course performed better than students but significantly worse than experts. Knowledge and skills in evidence based medicine increased after the course by 57% (mean score before course 6.3 (SD 2.9) v 9.9 (SD 2.8), P < 0.001). No difference was found among experts or students in absence of an intervention. Conclusions: The instrument reliably assessed knowledge and skills in evidence based medicine. An intensive 3 day course in evidence based medicine led to a significant increase in knowledge and skills.
Patients' attitudes to the summary care record and HealthSpace: Qualitative study
Objective: To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care. Design: 103 semistructured individual interviews and seven focus groups. Setting: Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation. Participants: Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants in a drug rehabilitation programme. Methods: Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances. Results: Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person's level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for "vulnerable groups." Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness. Conclusion: Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The "implied consent" model for creating and accessing a person's SCR should be revisited, perhaps in favour of "consent to view" at the point of access.
Effectiveness and efficiency of search methods in systematic reviews of complex evidence: Audit of primary sources
Objective To describe where papers come from in a systematic review of complex evidence. Method Audit of how the 495 primary sources for the review were originally identified. Results Only 30% of sources were obtained from the protocol denned at the outset of the study (that is, from the database and hand searches). Fifty one per cent were identified by "snowballing" (such as pursuing references of references), and 24% by personal knowledge or personal contacts. Conclusion Systematic reviews of complex evidence cannot rely solely on protocol-driven search strategies.
Making decisions about benefits and harms of medicines
Even when good scientific data are available, people's interpretation of risks and benefits will differ.
A comparative case study of two models of a clinical informaticist service
Objectives: To describe and evaluate two different models of a clinical informaticist service. Design A case study approach, using various qualitative methods to illuminate the complexity of the project groups' experiences. Setting UK primary health care. Interventions: Two informaticist projects to provide evidence based answers to questions arising in clinical practice and thereby support high quality clinical decision making by practitioners. Results: The projects took contrasting and complementary approaches to establishing the service. One was based in an academic department of primary health care. The service was academically highly rigorous, remained true to its original proposal, included a prominent research component, and involved relatively little personal contact with practitioners. This group achieved the aim of providing general information and detailed guidance to others intending to set up a similar service. The other group was based in a service general practice and took a much more pragmatic, flexible, and facilitative approach. They achieved the aim of a credible, acceptable, and sustainable service that engaged local practitioners beyond the innovators and enthusiasts and secured continued funding. Conclusion An informaticist service should be judged on at least two aspects of quality - an academic dimension (the technical quality of the evidence based answers) and a service dimension (the facilitation of questioning behaviour and implementation). This study suggests that, while the former may be best achieved within an academic environment, the latter requires a developmental approach in which pragmatic service considerations are addressed.
Introduction of shared electronic records: Multi-site case study using diffusion of innovation theory
Objective: To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care. Design: Multi-site, mixed method case study applying utilisation focused evaluation. Setting: Four early adopter sites for the SCR in England - three in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis: Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings: The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR's material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters' concerns (especially about workload and the ethicality of sharing "confidential" information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example, past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension forchange, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme). Conclusion: Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the microlevel by the material properties of the technology, individuals' attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care.