To describe and evaluate a community-based musculoskeletal service, commissioned by National Health Services North East Essex Primary Care Trust (PCT), in terms of patient-reported outcomes and satisfaction.

Persistent musculoskeletal conditions, including back and neck pain, are costly in terms of primary and secondary healthcare resources. Most patients are assessed and managed by general practitioners (GPs), with referral when necessary to secondary care services.

Patients consulting for at least four weeks for back or neck pain were referred by their GP according to patient preference to either a chiropractor or osteopath or physiotherapist working in the independent sector. Patients completed questionnaires at baseline and at discharge from the service.

Questionnaire data were obtained from 696 patients, 97% of whom were seen within two weeks. About half (51%) had had their pain for less than three months, and of the remainder 49% for more than 12 months. Patients received on average six treatments. Using the Bournemouth Questionnaire, the Bothersomeness scale and the Global Improvement Scale, approximately two-thirds (64.6%, 67.8% and 69.9%, respectively) reported improvement at discharge, and approximately 65% a significant reduction in medication. Almost all (99.5%) patients were satisfied with the service. Similarly, almost all (97%) patients were discharged from the service with advice on self-management; the remainder were recommended for secondary care referral.

This service improved patient access and choice resulting in shorter waiting times and effective outcomes. An impact analysis of the first 12 months of the service by the PCT showed a reduction in primary care consultations and in inappropriate referrals to secondary care.

The objective of this study was to assess determinants of poor sleep quality which is an under-diagnosed and under-treated problem in elderly patients with diabetes mellitus, hyperlipidemia and hypertension.

Poor sleep quality is linked to decreased quality of life, increased morbidity and mortality. Poor sleep quality is common in the elderly population with associated cardiometabolic risk factors such as diabetes, hyperlipidemia and hypertension.

This is a cross-sectional study undertaken in the primary healthcare setting (Singhealth Polyclinics-Outram) in Singapore. Singaporeans aged 65 years and above who had at least one of the three cardiometabolic risk factors (diabetes, hypertension and hyperlipidemia) were identified. Responders’ sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and were divided into those with good quality sleep and those with poor quality sleep, based on the PSQI score. Information on demographics, co-morbidities and lifestyle practices were collected. Descriptive and multivariate analyses of determinants of poor sleep were determined.

There were 199 responders (response rate 88.1%). Nocturia (adjusted prevalence rate ratio 1.54, 95% confidence interval 1.06–2.26) was found to be associated with an increased risk of poor sleep quality in elderly patients with diabetes mellitus, hypertension and hyperlipidaemia. Nocturia, a prevalent problem in the Asian elderly population, has been found to be associated with poor sleep quality in our study. Hence, it is imperative to identify and treat patients with nocturia to improve sleep quality among them.

In May 2020, the African Journal of Primary Health Care and Family Medicine invited submissions on lessons learnt from responses to the COVID-19 pandemic from primary care providers in Africa. This included descriptions of innovations and good practices, the management of COVID-19 in district health services and responses of communities to the outbreak.

To synthesise the lessons learnt from the COVID-19 pandemic in the Africa region.

A thematic document analysis was conducted on twenty-seven short report publications from Botswana, Ghana, Nigeria, South Africa, Uganda and Zimbabwe. Findings: Eight major themes were derived from the data: community-based activities; screening and testing; reorganisation of health services; emergency care for COVID-19; maintenance of essential non-COVID-19 health services; caring for the vulnerable; use of information technology; and reframing training opportunities. Community health workers were a vital community resource, delivering medications and other supplies to homes, as well as following up on patients with chronic conditions. More investment in community partnerships and social mobilisation was proposed. Difficulties with procurement of test kits and turn-around times were constraints for most countries. Authors described how services were reorganised for focused COVID-19 activities, sometimes to the detriment of essential services and training of junior doctors. Innovations in use of internet technology for communication and remote consultations were explored. The contribution of family medicine principles in upholding the humanity of patients and their families, clear leadership and planning, multidisciplinary teamwork and continuity of care was emphasised even in the context of providing critical care.

The community-orientated primary care approach was emphasised as well as long-term benefits of technological innovations. The pandemic exposed the need to deliver on governmental commitments to strengthening primary health care and universal health coverage.

The strain on health care services is increasing due to an ageing population and the increasing prevalence of chronic health conditions. eHealth could contribute to optimise effective and efficient care to older adults with one or more chronic health conditions in the general practice.

The aim of this study was to identify the needs, barriers and facilitators amongst community-dwelling older adults (60+) suffering from one or more chronic health conditions, in using online eHealth applications to support general practice services.

A qualitative study, using semi-structured followed by think-aloud interviews, was conducted in the Netherlands. The semi-structured interviews, supported by an interview guide were conducted and analysed thematically. The think-aloud method was used to collect data about the cognitive process while the participant was completing a task within online eHealth applications. Verbal analysis according to the Chi approach was conducted to analyse the think-aloud interviews.

A total of n = 19 older adults with a mean age of 73 years participated. The ability to have immediate contact with the GP on important health issues was identified as an important need. Identified barriers were non-familiarity with the online eHealth applications and a mismatch of user health needs. The low computer experience resulted in non-familiarity with the online eHealth applications. Faltering applications resulted in participants refusing to participate in the use of online eHealth applications. Convenience, efficiency and the instant availability of eHealth via applications were identified as important facilitators.

To improve the use and acceptability of eHealth applications amongst older adults in the general practice, the applications should be tailored to meet individual needs. More attention should be given to improving the user-friendliness of these applications and to the promotion of the benefits such as facilitating older adults independent living for longer.

The aim of this study was to prioritize hospital admissions for ambulatory care sensitive conditions (ACSCs) and interventions for future research and implementation.

Initiatives aimed at reducing hospital admission need to be targeted at those patients who could avoid admission to hospital, either by prevention, earlier detection and treatment, or by the provision of alternative types of care. Admissions for ACSCs should ideally be prevented by care provided outside hospital.

The study used a modified Delphi method to elicit the views of an expert panel. The Delphi process comprised two rounds and used a Web-based questionnaire. Participants were purposively sampled and comprised primary and community care clinicians, emergency clinicians and commissioning managers. Quantitative data were analysed to produce descriptive statistics. Qualitative data were analysed using content analysis.

A total of 36 participants responded to both rounds of the Delphi survey. The condition given top priority was dementia, not currently a widely recognized ACSC or a national priority. The proportion of admissions that could be avoided by provision of care outside hospital was the most important factor in deciding which conditions to prioritize. Access to rapid response nursing and social care at home, intermediate care beds and mental health crisis teams were identified as key interventions to reduce admissions. Analysis of qualitative data showed several themes underlying clinical decisions to admit potentially avoidable admissions.

In conclusion, the conditions selected by the panel for prioritization showed some concordance with the National Health Services’ priorities in this area; but the condition given top priority by the panel – dementia – is not currently a national priority. The panel showed a high degree of consensus around interventions that might lower the rate of avoidable admissions. The highest rated interventions involve the direct delivery of rapid access care in the community.

The aim of the present study was to assess the association of gestational diabetes mellitus (GDM) with prenatal and postnatal depressive symptoms in a sample of pregnant women in Greece.

Earlier research supports a relationship between depression and diabetes, but only a few studies have examined the relationship between GDM and perinatal depressive symptomatology.

A total of 117 women in their third trimester of pregnancy participated in the study. Demographic and obstetric history data were recorded during women’s third trimester of pregnancy. Depressive symptoms were assessed with the validated Greek version of the Edinburg Postnatal Depression Scale (EPDS) at two time points: on the third trimester of pregnancy and on the first week postpartum.

Prevalence of GDM was 14.5%. Probable diagnosis of depression occurred for 12% of the sample during the antenatal assessment and 15.1% in the postpartum assessment. In the first week postpartum, women with GDM had significantly higher postpartum (but no antenatal) EPDS scores compared with the non-GDM cohort. In conclusion, GDM appears to be associated with depressive symptoms in the first week postpartum. Clinical implications and recommendations for future research are discussed, emphasizing the importance of closely monitoring women with GDM who seem more vulnerable to developing depressive symptomatology during the postnatal period.

Depression in young people is not necessarily self-limiting, and is frequently associated with affective disorders and impaired psychosocial functioning in adult life. Early recognition of and response to depression in teenagers could be an important task for general practitioners (GPs), but there are multiple obstacles to achieving this.

To explore GPs perceptions of the opportunities and difficulties of working with teenagers, and of specifically recognizing and responding to depression.

Nine GPs who had taken part in a developmental project on diagnosing and treating depression in young people. All worked in an Inner London Medical Centre.

Semi-structured interviews transcribed and analysed thematically.

Two over-arching themes that emerged from the interviews were that teenagers were perceived as being qualitatively different from adults in the ways they used general practice, and that GPs were uncomfortable with making a diagnosis of depression in young people. Within the first theme, we identified sub-themes, including failure of teenagers to engage with services, parental involvement, complex presentations and lack of time. Within the second theme, the sub-themes were surprise, normalization of depressed mood and challenge to the validity of psychiatric diagnosis in this age group.

Professional development in general practice that addresses this topic needs to modify two perceptions; that depressed mood is in some sense ‘normal’ in this age group, and that teenagers are so different in their use of services that the management of depression (if it is recognized at all) is problematic.

The purpose of this study was to investigate the circumstances of opioid prescription among general practitioners (GPs) in the UK.

Prescription of opioids for chronic pain, particularly non-malignant chronic pain, remains controversial. In the midst of this controversy, patterns of actual prescription and influences on these patterns are not well understood.

A mail survey was posted to 1192 GPs and it was returned by 414 (35.0%). The survey addressed the frequency and reluctance in GP prescription of opioids for chronic pain. It also sampled their attitudes and concerns about opioids, including their views on appropriateness and effectiveness, adverse effects and potential social pressures presumed to impact on prescribing.

Overall, 57.9% of GPs reported they sometimes, frequently, or always, prescribe strong opioids for chronic pain, which was of significantly lower frequency than for prescribing of weak opioids, non-steroidal anti-inflammatory drugs (NSAIDs) or tricyclic antidepressant medications. Similarly, 69.1% reported a reluctance to prescribe strong opioids for chronic non-malignant pain, which was a significantly greater reluctance than for cancer pain, for example. GPs who were men, younger, had fewer years experience and worked full time (as opposed to part time), were more likely to prescribe opioids. Practice guideline use was unrelated to prescribing but those with specialty training were more likely to prescribe. Interestingly, a majority of GPs (83.0%) felt that opioids are effective for chronic non-malignant pain; however, they worry about long-term commitment (such as managing dosing and repeat prescriptions), addiction and other adverse events.

Based on multivariate analyses, both frequency of prescribing and reluctance were predicted by a combination of concerns about effects on patient behaviour, professional competency concerns and degree of belief in opioids as an effective option. These results may suggest a need for additional GP training in the management of analgesics for chronic non-malignant pain.

Insomnia is commonly associated with chronic health problems. Behavioural and cognitive factors often perpetuate a vicious cycle of anxiety and sleep disturbance, leading to long-term insomnia. National Institute for Health and Clinical Excellence currently recommends behavioural approaches before prescribing hypnotics. Behavioural approaches aim to treat underlying causes, but are not widely available. Research usually includes patients diagnosed with insomnia rather than secondary, co-morbid sleep- related problems.

To examine the effectiveness of autogenic training (AT) as a non-drug approach to sleep-related problems associated with chronic ill health.

Prospective pre- and post-treatment cohort study.

AT centre, Royal London Hospital for Integrated Medicine, University College London Hospitals NHS Foundation Trust.

All patients referred for AT from April 2007 to April 2008 were invited to participate. Participants received standard 8-week training, with no specific focus on sleep. Sleep questionnaires were administered at four time points, ‘Measure Your Medical Outcome Profile’ (MYMOP) and Hospital Anxiety and Depression Scale, before and after treatment. Results before and after treatment were compared. Camden and Islington Community Local Research and Ethics Committee approved the study.

The AT course was completed by 153 participants, of whom 73% were identified as having a sleep-related problem. Improvements in sleep patterns included: sleep onset latency (P = 0.049), falling asleep quicker after night waking (P < 0.001), feeling more refreshed (P < 0.001) and more energised on waking (P = 0.019). MYMOP symptom, well-being, anxiety and depression scores significantly improved (all P < 0.001).

This study suggests that AT may improve sleep patterns for patients with various health conditions and reduce anxiety and depression, both of which may result from and cause insomnia. Improvements in sleep patterns occurred despite, or possibly due to, not focusing on sleep during training. AT may provide an approach to insomnia that could be incorporated into primary care.

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.

Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

This article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients.

Substance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse.

We conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements.

The conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients’ increased knowledge of available treatment resources, and health outcomes such as patients’ reduced substance use and better quality of life.

The home-based Otago Exercise Programme has been shown to increase sustained physical-activity levels in older people recruited through primary care, when supported by health professionals. The ProAct65+ trial is testing this programme using volunteer peer mentors to support behaviour change. This qualitative study explored how these peer mentors experienced their role.

Ten peer mentors from the ProAct65+ trial were interviewed. Semi-structured interviews were audio-recorded, transcribed verbatim and thematically analysed.

Peer mentors reported positive experiences including meeting new people, watching mentees progress, developing friendships and being shown gratitude for their support. Key barriers and facilitators to the mentoring process included the home and telephone as settings for support, geography and making contact with mentees.

Findings from this study can help the development of peer mentor programmes in primary care for older people. Future programmes should recruit peer mentors who are local to where mentoring is needed to reduce travel difficulties.

The aim of the study was to describe practices that support collaboration in interprofessional primary health care teams, and identify performance indicators perceived to measure the impact of this collaboration from the perspective of interprofessional health providers.

Despite the surge of interprofessional primary health care models implemented across Canada, there is little evidence as to whether or not the intended outcomes of primary health care teams have been achieved. Part of the challenge is determining the most appropriate measures that can demonstrate the value of collaborative care. To date, little remains known about performance measurement from the providers contributing to the collaborative care process in interprofessional primary care teams. Having providers from a range of disciplinary backgrounds assist in the development of performance measures can help identify measures most relevant to demonstrate the value of collaborative care on the intended outcomes of interprofessional primary care models.

A qualitative study; part of a larger mixed methods developmental evaluation to examine performance measurement in interprofessional primary health care teams. A stakeholder workshop was conducted at an annual association meeting of interprofessional primary health care teams in the province of Ontario, Canada. Six questions guided the workshop groups and participant responses were documented on worksheets and flip charts. All responses were collected and entered verbatim into a word document. Qualitative analytic strategies were applied to each question.

A total of 283 primary health care providers from 14 health professions working in interprofessional primary health care teams participated. Top three elements of interprofessional collaboration (total n = 628) were communication (n = 146), co-treatment (n = 112) and patient-based conferences (n = 81). Top three performance indicators currently used to demonstrate the value of interprofessional collaboration (total n = 241) were patient experience (n = 71), patient health status (n = 35) and within team referrals (n = 30).

To synthesize information about management of end of life care in people with dementia using review papers.

There are increasing numbers of people being diagnosed with dementia worldwide, and the needs of people with dementia and their carers at the end of life may be different from those with other chronic diseases. By highlighting the challenges of palliative care in persons with dementia and the ways they are best managed, practitioners in primary care may be able to improve services for this group of people at the end of life.

A search of electronic databases of English language papers published in peer-reviewed journals, 2000–2011 inclusive was undertaken using broad terms related to palliative care and dementia. 6167 papers were identified. Titles and abstracts were read. Papers were included if they were literature reviews of palliative or end of life care for people with dementia/Parkinson's disease/Lewy body dementia/cognitive impairment/Alzheimer's disease or any other cognitive impairment, in any setting (hospital, care home, community) and covering people of all ages. Papers were excluded if they covered palliative care focusing on other conditions, or were about an aspect of dementia care and treatment not related to palliative care.

Our critical synthesis generated five main themes from this review of the reviews: (1) carers’ (family caregivers’) experiences; (2) person-centred care; (3) practice (including advance care planning, pain and comfort, nutrition, medical complications and minimizing the distress of behavioural symptoms); (4) system factors, including ethical dilemmas, decision making, information, and training; and (5) research priorities. There appears to be good evidence on the care and management of patients with dementia at the end of life which can be used to influence policy development and emerging specificity about research priorities in palliative care practice for people with dementia.

The principal aim of this study was to develop, pilot and evaluate an intervention intended to support the development of resilience and self-efficacy in parents of children with disabilities or complex health needs.

Previous research has found that families often experience physical, social and emotional stress in the context of living with and caring for their disabled child. The literature indicates that a key factor in determining how well the parents of these children cope with their situation may be how resilient and self-efficacious they are.

A total of 16 parents of children with complex needs and disabilities were engaged in a series of guided conversations delivered during six contact visits with nurse co-researchers (community children’s nurses who had received an intensive three-day preparation programme). The conversations, which were supported with additional material that was designed specifically for use in the study, were based around four key themes: emotional coping, practical coping, support networks and ‘you and your child’. The impact of the intervention was evaluated using both qualitative and quantitative measures.

When interviewed, parents reported increased self-belief and self-confidence and indicated that they felt better supported and stronger as a result of the intervention. This was consistent with the quantitative evaluation which identified significant improvements on scores for active coping and self-blame on the brief COPE inventory scale and for empathy and understanding and self-acceptance on the TOPSE scale. Scores on the self-report distress thermometer demonstrated a significant reduction in self-reported distress scores at the end of the intervention period.

To map the availability and types of depression and anxiety groups, to examine men's experiences and perception of this support as well as the role of health professionals in accessing support.

The best ways to support men with depression and anxiety in primary care are not well understood. Group-based interventions are sometimes offered but it is unknown whether this type of support is acceptable to men.

Interviews with 17 men experiencing depression or anxiety. A further 12 interviews were conducted with staff who worked with depressed men (half of whom also experienced depression or anxiety themselves). There were detailed observations of four mental health groups and a mapping exercise of groups in a single English city (Bristol).

Some men attend groups for support with depression and anxiety. There was a strong theme of isolated men, some reluctant to discuss problems with their close family and friends but attending groups. Peer support, reduced stigma and opportunities for leadership were some of the identified benefits of groups. The different types of groups may relate to different potential member audiences. For example, unemployed men with greater mental health and support needs attended a professionally led group whereas men with milder mental health problems attended peer-led groups. Barriers to help seeking were commonly reported, many of which related to cultural norms about how men should behave. General practitioners played a key role in helping men to acknowledge their experiences of depression and anxiety, listening and providing information on the range of support options, including groups. Men with depression and anxiety do go to groups and appear to be well supported by them. Groups may potentially be low cost and offer additional advantages for some men. Health professionals could do more to identify and promote local groups.

To describe the characteristics of people in Central and Eastern Sydney (CES), NSW, who had a General Practice Management Plan (GPMP) and claimed for at least one private allied health service item; and to examine if allied health service use results in less hospitalisations over a five-year period.

The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management programme was introduced to the Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The programme supports general practitioners claiming up to one GPMP and one Team Care Arrangement every year, and the patient additionally claiming for up to five private allied health services visits.

A prospective longitudinal study was conducted. The sample consisted of 5771 participants in CES who had a GPMP within a two-year health service utilisation baseline period (2007–2009). The analysis used the 45 and Up Study questionnaire data linked to the MBS, hospitalisation, death and emergency department data for the period 2006–2014.

Of the eligible participants, 43% (2460) had at least one allied health service item claim in the subsequent 12 months. Allied health services were reported as physiotherapy, podiatry and other allied health services. The highest rates of allied health service use were among participants aged 85 years and over (49%). After controlling for confounding factors, a significant difference was found between having claimed for five or more physiotherapy services and emergency admissions (HR: 0.83; 95% CI: 0.72–0.95) and potentially preventable hospitalisations (HR: 0.79; 95% CI: 0.64–0.96) in the subsequent five years. Use of allied health service items was well targeted towards those with chronic and complex care needs, and use of physiotherapy services was associated with less avoidable hospitalisations.