Search results
Found 19987 matches for
We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation
Background: Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D). Methods: Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods. Results: People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17–4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27–1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients’ wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness. Conclusions: Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.
Theorising Support for Interdisciplinary Early-Career Researchers Using Communicative Genre and ‘Rules of the Game’
Qualitative social scientists working in medical faculties have to meet multiple expectations. On the one hand, they are expected to comply with the philosophical and theoretical expectations of the social sciences. On the other hand, they may also be expected to produce publications which align with biomedical definitions and framings of quality. As interdisciplinary scholars, they must handle (at least) two sets of journal editors, peer reviewers, grant-awarding panels, and conference audiences. In this paper, we extend the current knowledge base on the ‘dual expectations’ challenge by drawing on Orlikowski and Yates’ theoretical concept of communicative genres. A ‘genre’ in this context is a format of communication (e.g. letter, email, academic paper, and conference presentation) aimed at a particular audience, having a particular material form and socio-linguistic style, and governed by both formal requirements and unwritten social rules. Becoming a member of any community of practice involves becoming familiar with its accepted communicative genres and adept in using them. Academic writing, for example, is a craft that is learned through participation in the social process of communicating one’s ideas to one’s peers in journal articles and other formats. In this reflective paper, we show how the concept of a communicative genre can sensitise us to the conflicting and often dissonant expectations and rule systems governing different academic fields. We use this key concept to suggest ways in which the faculty can support early-career researchers to progress in careers which straddle qualitative social science and medical science.
Why do GPs rarely do video consultations? qualitative study in UK general practice
Background Fewer than 1% of UK general practice consultations occur by video. Aim To explain why video consultations are not more widely used in general practice. Design and setting Analysis of a sub-sample of data from three mixed-method case studies of remote consultation services in various UK settings from 2019–2021. Method The dataset included interviews and focus groups with 121 participants from primary care (33 patients, 55 GPs, 11 other clinicians, nine managers, four support staff, four national policymakers, five technology industry). Data were transcribed, coded thematically, and then analysed using the Planning and Evaluating Remote Consultation Services (PERCS) framework. Results With few exceptions, video consultations were either never adopted or soon abandoned in general practice despite a strong policy push, short-term removal of regulatory and financial barriers, and advances in functionality, dependability, and usability of video technologies (though some products remained ‘fiddly’ and unreliable). The relative advantage of video was perceived as minimal for most of the caseload of general practice, since many presenting problems could be sorted adequately and safely by telephone and in-person assessment was considered necessary for the remainder. Some patients found video appointments convenient, appropriate, and reassuring but others found a therapeutic presence was only achieved in person. Video sometimes added value for out-of-hours and nursing home consultations and statutory functions (for example, death certification). Conclusion Efforts to introduce video consultations in general practice should focus on situations where this modality has a clear relative advantage (for example, strong patient or clinician preference, remote localities, out-of-hours services, nursing homes).
Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study
Orthostatic intolerance (OI), including postural orthostatic tachycardia syndrome (PoTS) and orthostatic hypotension (OH), are often reported in long covid, but published studies are small with inconsistent results. We sought to estimate the prevalence of objective OI in patients attending long covid clinics and healthy volunteers and associations with OI symptoms and comorbidities. Participants with a diagnosis of long covid were recruited from eight UK long covid clinics, and healthy volunteers from general population. All undertook standardized National Aeronautics and Space Administration Lean Test (NLT). Participants' history of typical OI symptoms (e.g., dizziness, palpitations) before and during the NLT were recorded. Two hundred seventy-seven long covid patients and 50 frequency-matched healthy volunteers were tested. Healthy volunteers had no history of OI symptoms or symptoms during NLT or PoTS, 10% had asymptomatic OH. One hundred thirty (47%) long covid patients had previous history of OI symptoms and 144 (52%) developed symptoms during the NLT. Forty-one (15%) had an abnormal NLT, 20 (7%) met criteria for PoTS, and 21 (8%) had OH. Of patients with an abnormal NLT, 45% had no prior symptoms of OI. Relaxing the diagnostic thresholds for PoTS from two consecutive abnormal readings to one abnormal reading during the NLT, resulted in 11% of long covid participants (an additional 4%) meeting criteria for PoTS, but not in healthy volunteers. More than half of long covid patients experienced OI symptoms during NLT and more than one in 10 patients met the criteria for either PoTS or OH, half of whom did not report previous typical OI symptoms. We therefore recommend all patients attending long covid clinics are offered an NLT and appropriate management commenced.
Theorising the shift to video consulting in the UK during the COVID-19 pandemic: Analysis of a mixed methods study using practice theory
We studied video consulting in the National Health Service during 2020–2021 through video interviews, an online survey and online discussions with people who had provided and participated in such consultations. Video consulting had previously been used for selected groups in limited settings in the UK. The pandemic created a seismic shift in the context for remote consulting, in which video transformed from a niche technology typically introduced by individual clinicians committed to innovation and quality improvement to offering what many felt was the only safe way to deliver certain types of healthcare. A new practice emerged: a co-constitution of technology and healthcare made possible by new configurations of equipment, connectivity and physical spaces. Despite heterogeneous service settings and previous experiences of video consulting, we found certain kinds of common changes had made video consulting possible. We used practice theory to analyse these changes, interpreting the commonalities found in our data as changes in purpose, material arrangements and a relaxing of rules about security, confidentiality and location of consultations. The practice of video consulting was equivocal. Accounts of, and preferences for, video consulting varied as did the extent to which it was sustained after initial take-up. People made sense of video consulting in different ways, ranging from interpreting video as offering a new modality of healthcare for the future to a sub-optimal, temporary alternative to in-person care. Despite these variations, video consulting became a recognisable social phenomenon, albeit neither universally adopted nor consistently sustained. The nature of this social change offers new perspectives on processes of implementation and spread and scale-up. Our findings have important implications for the future of video consulting. We emphasise the necessity for viable material arrangements and a continued shared interpretation of the meaning of video consulting for the practice to continue.
Independent SAGE as an example of effective public dialogue on scientific research
The World Health Organization declared COVID-19 to be a public health emergency of international concern on 30 January 2020 and then a pandemic on 11 March 2020. In early 2020, a group of UK scientists volunteered to provide the public with up-to-date and transparent scientific information. The group formed the Independent Scientific Advisory Group for Emergencies (Independent SAGE) and provided live weekly briefings to the public via YouTube. In this Perspective, we describe how and why this group came together and the challenges it faced. We reflect on 4 years of scientific information broadcasting and discuss the guiding principles followed by Independent SAGE, which may be broadly transferable for strengthening the scientist–public dialogue during public health emergencies in future settings. We discuss the provision of clarity and transparency, engagement with the science–policy interface, the practice of interdisciplinarity, the centrality of addressing inequity, the need for dialogue and partnership with the public, the importance of support for advocacy groups, the diversification of communication channels and modalities, the adoption of regular and organized internal communications, the resourcing and support of the group’s communications and the active opposition of misinformation and disinformation campaigns. We reflect on what we might do differently next time and propose research aimed at building the evidence base for optimizing informal scientific advisory groups in crisis situations.
After the disruptive innovation: How remote and digital services were embedded, blended and abandoned in UK general practice - longitudinal study.
BACKGROUND: United Kingdom general practices transitioned rapidly to remote-by-default services in 2020 and subsequently considered whether and how to continue these practices. Their diverse responses provided a unique opportunity to study the longer-term embedding, adaptation and abandonment of digital innovations. Research questions: What was the range of responses to the expansion of remote and digital triage and consultations among United Kingdom general practices in the period following the acute phase of the coronavirus disease discovered in 2019 (COVID-19) pandemic? What can we learn from this example about the long-term impacts of crisis-driven sociotechnical change in healthcare settings? METHODS: We collected longitudinal data from 12 general practices from 2021 to 2023, comprising 500 hours of ethnographic observation, 163 interviews in participating practices and linked organisations (132 staff, 31 patients), 39 stakeholder interviews and 4 multi-stakeholder workshops (210 participants), with additional patient and public involvement input. Data were de-identified, uploaded to NVivo (QSR International, Warrington, UK) and synthesised into case studies, drawing on theories of organisational innovation. RESULTS: General practices' longitudinal progress varied, from a near-total return to traditional in-person services to extensive continuing use of novel digital technologies and pathways. Their efforts to find the right balance were shaped and constrained by numerous contextual factors. Large size, slack resources, high absorptive capacity, strong leadership and good intrapractice relationships favoured innovation. Readiness for remote and digital modalities varied depending on local tension for change, practice values and patient characteristics. Technologies' uptake and use were influenced by their material properties and functionality. Embedding and sustaining technologies required ongoing work to adapt and refine tasks and processes and adjust (or, where appropriate, selectively abandon) technologies. Adoption and embedding of technologies were affected by various staff and patient factors. When technologies fitted poorly with tasks and routines or when embedding efforts were unsuccessful, inefficiencies and 'techno-stress' resulted, with compromises to patient access and quality of care. LIMITATIONS: Sampling frame was limited to United Kingdom and patient interviews were relatively sparse. CONCLUSION: There is wide variation in digital maturity among United Kingdom general practices. Low use of remote and digital technologies and processes may be warranted and reflect local strategic choices, but it may also indicate lack of awareness and a reactive rather than strategic approach to digital innovation. We offer an updated typology of digital maturity in general practice with suggestions for tailored support. FUTURE WORK: The typology of digital maturity could be applied further to identify in more detail the kind of support needed for practices that are at different stages of maturity and are serving different populations. The need for strategically traditional practices in deprived settings should also be explored. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132807.
Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research
Background: The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. Aim: To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. Design & setting: Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. Method: Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. Results: The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). Conclusion: Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.
Integrating System Dynamics and Action Research: Towards a Consideration of Normative Complexity Comment on “Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research”
Holmström and co-authors argue for the value of integrating system dynamics into action research to deal with increasing complexity in healthcare. We argue that despite merits, the authors overlook the key aspect of normative complexity, which refers to the existence of multiple, often conflicting values that actors in healthcare systems have to pragmatically develop responses to in their daily practices. We argue that a better theoretical and empirical understanding of the multiplicity of values and how actors deal with value conflicts in daily practices can enrich discussions about complexity in healthcare. We introduce the alternative methodology of ‘value exnovation’ for action researchers to broaden the scope of system-based thinking and action research in healthcare.
Food beliefs and practices among British Bangladeshis with diabetes: implications for health education
In order successfully to promote ‘healthier’ food choices, health professionals must first understand how people classify and select the foods they eat. We explored the food beliefs and classification system of British Bangladeshis by means of qualitative interviews with 40 first-generation adult immigrants with diabetes. Methods included audiotaped, unstructured narrative interview in which participants were invited to ‘.tell the story’ of how diabetes affects them, pile sorting of food items, and participant observation of meals. We found considerable heterogeneity of individual food choices against a background of structural and economic factors (i.e. food choices were partly determined by affordability and availability), as well as cultural influences. Important themes included strong religious restrictions on particular food items (chiefly the Islamic prohibition of pork), and widely held ethnic customs based on the availability of foods in rural Bangladesh. Modification of the diet on immigration did not generally incorporate many Western’ foods but included increased quantities of ‘special menu’ Bangladeshi foods such as meat and traditional sweets. Foods were not classified or selected according to Western notions of food values (protein, carbohydrate, etc.). Rather, within religious and ethnic patterns, further food choices were determined by two interrelated and intersecting binary classification systems: ‘strong’/‘weak’ and ‘digestible’/‘indigestible’, which appear to replace the ‘hot’/‘cold’ classification prevalent elsewhere in South Ada. Different methods of cooking (especially baking and grilling) were perceived to alter the nature of the food. A desire for dietary balance, and a strong perceived link with health, was apparent. These findings have important implications for the design of health education messages. Dietary advice should reflect religious restrictions, ethnic customs and the different cultural meaning of particular foods, while also acknowledging the ability of the individual to exercise choice within those broad limits.
LOng COvid Multidisciplinary consortium Optimising Treatments and servIces acrOss the NHS (LOCOMOTION): Protocol for a mixed-methods study in the UK
Introduction Long COVID, a new condition whose origins and natural history are not yet fully established, currently affects 1.5 million people in the UK. Most do not have access to specialist long COVID services. We seek to optimise long COVID care both within and outside specialist clinics, including improving access, reducing inequalities, helping self-management and providing guidance and decision support for primary care. We aim to establish a 'gold standard' of care by systematically analysing current practices, iteratively improving pathways and systems of care. Methods and analysis This mixed-methods, multisite study is informed by the principles of applied health services research, quality improvement, co-design, outcome measurement and learning health systems. It was developed in close partnership with patients (whose stated priorities are prompt clinical assessment; evidence-based advice and treatment and help with returning to work and other roles) and with front-line clinicians. Workstreams and tasks to optimise assessment, treatment and monitoring are based in three contrasting settings: workstream 1 (qualitative research, up to 100 participants), specialist management in 10 long COVID clinics across the UK, via a quality improvement collaborative, experience-based co-design and targeted efforts to reduce inequalities of access, return to work and peer support; workstream 2 (quantitative research, up to 5000 participants), patient self-management at home, technology-supported monitoring and validation of condition-specific outcome measures and workstream 3 (quantitative research, up to 5000 participants), generalist management in primary care, harnessing electronic record data to study population phenotypes and develop evidence-based decision support, referral pathways and analysis of costs. Study governance includes an active patient advisory group. Ethics and dissemination LOng COvid Multidisciplinary consortium Optimising Treatments and servIces acrOss the NHS study is sponsored by the University of Leeds and approved by Yorkshire & The Humber - Bradford Leeds Research Ethics Committee (ref: 21/YH/0276). Participants will provide informed consent. Dissemination plans include academic and lay publications, and partnerships with national and regional policymakers.
Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study protocol (TOGETHER 2)
Background: General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs) providing clinical care to multiple patients at the same time. Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. Objectives: To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Methods: Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. Conclusions: We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.
What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography
Background: Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called “postcode lottery” of care. The original aim of this study—to examine the nature of quality in long covid care and reduce unwarranted variation in services—evolved to focus on examining the reasons why standardizing care was so challenging in this condition. Methods: In 2021–2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge. Results: Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). Conclusion: Not all variation in long covid services is unwarranted. Largely because long covid’s manifestations are so varied and comorbidities common, generic “evidence-based” standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients’ unique needs. Study registration: NCT05057260, ISRCTN15022307.