To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles.

The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses.

A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles.

A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients.

This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

Age UK Lancashire received Big Lottery funding to deliver an active lives programme from January 2012 to December 2014 to the population of West Lancashire aged over 50 years. The overall aims of the associated evaluation were to measure older people’s experiences of participating in the programme, identify the impacts on their health and well-being and their suggestions for services development, and establish the costs and benefits of the programme.

The World Health Organisation recommends older people should be able to achieve physical, social and mental well-being throughout their lives, and that international, national and local policies should be developed to support older adults, promote their independence and well-being, and encourage physical exercise. Consequently, the West Lancashire programme was to establish preventative community support for older people to assist in improving their well-being and physical and mental health, particularly those isolated due to age-related illness or disability. It was to provide interventions not available from local social care providers.

A mixed methods approach was adopted, with the qualitative evaluation utilising focus groups to establish people’s experiences, identify impacts on their health and well-being, and suggestions for services development. This paper describes the quantitative evaluation, which involved three surveys and a costs analysis. The surveys were scheduled to give timely feedback to management about programme delivery and content, and overall benefits of participation.

The active lives programme and groups offered a wide range of flexible and local activities that provided benefits for older people in terms of health and well-being, social well-being and quality of life, and reducing social isolation. There was interconnectivity between these benefits. The programme was delivered in an affordable and flexible manner. Such programmes should be made more widely available.

To examine how patient perspectives and person-centred care values have been represented in documents on medicines optimisation policy in England.

There has been growing support in England for a policy of medicines optimisation as a response to the rise of problematic polypharmacy. Conceptually, medicines optimisation differs from the medicines management model of prescribing in being based around the patient rather than processes and systems. This critical examination of current official and independent policy documents questions how central the patient is in them and whether relevant evidence has been utilised in their development.

A documentary analysis of reports on medicines optimisation published by the Royal Pharmaceutical Society (RPS), The King’s Fund and National Institute for Health and Social Care Excellence since 2013. The analysis draws on a non-systematic review of research on patient experiences of using medicines.

The reports varied in their inclusion of patient perspectives and person-centred care values, and in the extent to which they drew on evidence from research on patients’ experiences of polypharmacy and medicines use. In the RPS report, medicines optimisation is represented as being a ‘step change’ from medicines management, in contrast to the other documents which suggest that it is facilitated by the systems and processes that comprise the latter model. Only The King’s Fund report considered evidence from qualitative studies of people’s use of medicines. However, these studies are not without their limitations.

We suggest five ways in which researchers could improve this evidence base and so inform the development of future policy: by facilitating reviews of existing research; conducting studies of patient experiences of polypharmacy and multimorbidity; evaluating medicines optimisation interventions; making better use of relevant theories, concepts and tools; and improving patient and public involvement in research and in guideline development.

Improving dementia diagnosis rates in England has been a key strategic aim of the UK Government but the variation and low diagnosis rates are poorly understood. The aim of this study was to explore the variation in actual versus expected diagnosis of dementia across England, and how these variations were associated with general practice characteristics.

A cross-sectional, ecological study design using secondary data sources and median regression modelling was used. Data from the year 2011 for 7711 of the GP practices in England (92.7%). Associations of dementia diagnosis rates (%) per practice, calculated using National Health Service England’s ‘Dementia Prevalence Calculator’ and various practice characteristics were explored using a regression model.

The median dementia diagnosis rate was 41.6% and the interquartile range was 31.2–53.9%. Multivariable regression analysis demonstrated positive associations between dementia diagnosis rates and deprivation of the population, overall Quality and Outcomes Framework performance, type of primary care contract and size of practice list. Negative associations were found between dementia diagnosis rates and average experience of GPs in the practice and the proportion of the practice caseload over 65 years old.

Dementia diagnosis rates vary greatly across GP practices in England. This study has found independent associations between dementia diagnosis rates and a number of patient and practice characteristics. Consideration of these factors locally may provide targets for case-finding interventions and so facilitate timely diagnosis.

We report on a formative project to develop an organization-level planning framework for obesity prevention and management services.

It is common when developing new services to first develop a logic model outlining expected outcomes and key processes. This can be onerous for single primary care organizations, especially for complex conditions like obesity.

The initial draft was developed by the research team, based on results from provider and patient focus groups in one large Family Health Team (FHT) in Ontario. This draft was reviewed and activities prioritized by 20 FHTs using a moderated electronic consensus process. A national panel then reviewed the draft.

Providers identified five main target groups: pregnancy to 2, 3–12, 13–18, 18+ years at health risk, and 18+ with complex care needs. Desired outcomes were identified and activities were prioritized under categories: raising awareness (eg, providing information and resources on weight-health), identification and initial management (eg, wellness care), follow-up management (eg, group programs), expanded services (eg, availability of team services), and practice initiatives (eg, interprofessional education). Overall, there was strong support for raising awareness by providing information on the weight-health connection and on community services. There was also strong support for growth assessment in pediatric care. In adults, there was strong support for wellness care/health check visits and episodic care to identify people for interventions, for group programs, and for additional provider education.

Joint development by different teams proved useful for consensus on outcomes and for ensuring relevancy across practices. While priorities will vary depending on local context, the basic descriptions of care processes were endorsed by reviewers. Key next steps are to trial the use of the framework and for further implementation studies to find optimally effective approaches for obesity prevention and management across the lifespan.

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.

To understand enablers and barriers influencing postpartum screening for type 2 diabetes following gestational diabetes in Australian Indigenous women and how screening might be improved.

Australian Indigenous women with gestational diabetes mellitus (GDM) are less likely than other Australian women to receive postpartum diabetes screening. This is despite a fourfold higher risk of developing type 2 diabetes within eight years postpartum.

We conducted interviews with seven Indigenous women with previous GDM, focus groups with 20 Indigenous health workers and workshops with 24 other health professionals. Data collection included brainstorming, visualisation, sorting and prioritising activities. Data were analysed thematically using the Theoretical Domains Framework. Barriers are presented under the headings of ‘capability’, ‘motivation’ and ‘opportunity’. Enabling strategies are presented under ‘intervention’ and ‘policy’ headings.

Participants generated 28 enabling environmental, educational and incentive interventions, and service provision, communication, guideline, persuasive and fiscal policies to address barriers to screening and improve postpartum support for women. The highest priorities included providing holistic social support, culturally appropriate resources, improving Indigenous workforce involvement and establishing structured follow-up systems. Understanding Indigenous women’s perspectives, developing strategies with health workers and action planning with other health professionals can generate context-relevant feasible strategies to improve postpartum care after GDM. Importantly, we need evidence which can demonstrate whether the strategies are effective.

To evaluate the impact and acceptability of offering one-to-one lifestyle interventions delivered by lay health trainers in the primary care setting.

Chronic conditions represent major causes of ill-health, avoidable disability, pain and anxiety, and tend to be more prevalent in less affluent groups. This is due, in part, to the link between unhealthy lifestyles and lower socio-economic status, although factors such as poverty, worklessness and social exclusion play a larger role. Lay health trainers were introduced in England with the aim of providing personalised lifestyle advice, support and access to services for people living in disadvantaged areas. There is a body of literature on the effectiveness of lay or community health workers in the management of chronic conditions. However, little is known about their potential to promote lifestyle changes in newly diagnosed patients. An innovative health trainer service was piloted in the primary care setting, to work with people diagnosed with a chronic condition or identified as potentially benefitting from one-to-one support.

A mixed method study design was utilised. Semi-structured interviews and focus groups were conducted with practice staff (n=11) and patients (n=15) from one primary care practice in North East England, United Kingdom. Discussions were audio-recorded and analysed using a thematic content approach. Routinely collected pre-/post-intervention data (n=246 patients at baseline; sample sizes varied at end line) were analysed and appropriate descriptive and summary statistics produced.

The discussions highlighted a high level of satisfaction with the health trainer model in terms of supporting positive lifestyle changes. Locating the intervention within the practice removed access barriers, particularly for those with long-term conditions. Anecdotal evidence of health improvement was supported by the quantitative analyses, which revealed statistically significant improvements in body mass index, blood pressure, dietary habits, exercise levels, alcohol intake, self-rated health and self-efficacy amongst those who completed the intervention.

Older people >65 years will rise significantly in coming years. Increased age is associated with risk of disability, illness and need for public health services. Preventive home visits is assumed to help older people to maintain their functional level longer, delaying disease and thus delaying the need for health care.

Descriptive explorative design describing the development, utilization and feasibility of preventive home visits in two different settings. All 77-year-old persons living at home in an urban municipality and all 75 years and older in a rural municipality were invited to participate. A questionnaire including a substantial number of tests concerning; fall, nutrition, polypharmacy and cognitive impairment was used by Health Team Nurses as base for a risk assessment. Pilot studies were conducted to validate the questionnaire including an inter-rater reliability study of the risk assessment tool. A multiprofessional team, Health Team for the Elderly met each week to evaluate risk assessments and make recommendations to be sent to each respective general practitioner. Data were analysed using descriptive and inferential statistics. In total, 167 persons (109 from the urban municipality and 58 from the rural municipality) participated, corresponding to 60% of the approached individuals. The mean time for the visits was 108 minutes (SD 20). Missing data were identified for; Do you feel safe in your municipality (17.5%) and Are you looking forward to ageing (11.4%). In total, 36 persons (21.7%) were identified with increased risk for developing illness. We suggest that a structured model of preventive home visits and collaboration between highly specialized health care professionals are important factors for reliable health promoting risk assessments of elderly home dwellers.

The purpose of this study is to assess the effectiveness of diabetes self-management education (DSME) in a rural agricultural town.

In this prospective, education-intervention trial, 85 adults with type 2 diabetes mellitus from villages randomly assigned to DSME and 70 from villages assigned to standard care participated. The DSME group underwent a curriculum delivered by peer educators; those in the standard group received usual advice. Outcome measures were anthropometric, biochemical, health behaviors, and medication use data taken at baseline then after three and six months.

DSME group had a lower median A1C after three and six months. After six months, there was a 0.5% median A1C reduction in DSME group and a 0.25% increase in the standard group. There were more participants in DSME group with A1C ⩽7.0% after three and six months. By the third month, there were more participants in DSME group performing foot examination.

DSME in this rural agricultural town improved glycemic control and promoted foot examination.

Older people from deprived areas, the oldest old and those from ethnic minorities engage less in health promotion interventions and related research, potentially generating inequities.

To explore and map the extent to which such ‘hard to reach’ groups of older people, are the focus of local health and well-being strategies in England.

Document analysis of current health and well-being promotion strategies in a purposive sample of 10 localities in England with high proportions of some or all of the three hard to reach groups. Documents were analysed using an interpretive approach.

A total of 254 documents were retrieved and reviewed. Much of the content of the documents was descriptive and reported the implications for resources/services of population ageing rather than actual initiatives. All localities had an Older People’s Strategy. Strategies to counter deprivation included redistribution of winter fuel payments, income maximisation, debt reduction and social inclusion initiatives, a focus on older owner occupiers and recruitment of village ‘agents’ to counter rural deprivation. The needs of the oldest old were served by integrated services for older people, a community alarm service with total coverage of the 85+ population, and dietary advice. The needs of black and minority ethnic (BME) older people were discussed in all localities and responses included community work with BME groups, attention to housing needs and monitoring of service use by BME older people. Three other themes that emerged were: use of telecare technologies; a challenge to the idea of ‘hard to reach’ groups; and outreach services to those at most risk.

Document analysis revealed a range of policy statements that may indicate tailoring of policy and practice to local conditions, the salience of national priorities, some innovative local responses to policy challenges and even dissenting views that seek to redefine the policy problem.

To investigate whether the use of long-acting benzodiazepines, in individuals aged 65 and over is mediated by physical or psychological factors.

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors.

Secondary analysis of baseline data from a study of 1059 community-dwelling non-disabled people aged 65 years and over recruited from three general practices in London. For this analysis, use of long-acting benzodiazepines was defined as any self-reported use of diazepam or nitrazepam in the last four weeks. Associations between demographic factors, health service use, and physical and psychological characteristics and benzodiazepine use were investigated.

The prevalence of benzodiazepine use in this sample was 3.3% (35/1059). In univariate analyses, benzodiazepine use was associated with female gender, low income, high consultation rates, physical factors (medication for arthritis or joint pain, polypharmacy, difficulties in instrumental activities of daily living, recent pain) and psychological factors (poor self-perceived health, social isolation, and symptoms of anxiety or agitation). In a multivariate logistic regression analysis only two factors retained statistically significant independent associations with benzodiazepine use: receiving only the state pension (OR=4.0, 95% CI: 1.70, 9.80) and pain in the past four weeks (OR=3.79, 95% CI: 1.36, 10.54).

This study aimed to explore, describe and enhance understanding of women’s experiences, beliefs and knowledge of urinary symptoms in the postpartum period and also sought to understand the perceptions of health professionals of these issues.

Women often take no action with regard to urinary symptoms particularly in the postnatal period, which can lead to the adoption of coping mechanisms or normalisation of symptoms. The true prevalence is difficult to assess due to differing age groups and time spans in studies. There is only a small body of work available to try to understand the lack of action on the part of the women, and even less around the attitudes of health professionals.

Grounded theory was selected for a qualitative inductive approach, to attempt to understand the social processes involved and generate new knowledge by examining the different interactions. Recruitment was by theoretical sampling. In total, 15 women were interviewed and two focus groups of health professionals were undertaken. In addition, an antenatal clinic and a postnatal mothers group were observed. All information was analysed manually using constant comparison.

The findings revealed that at times poor communication, lack of clear education and the power of relative’s stories of the past were barriers to help seeking, and were disempowering women, creating a climate for normalisation. Women were willing to talk but preferred the health professional to initiate discussion. In addition, health professionals were concerned about a lack of time and knowledge and were uncertain of the effect of pelvic floor muscle exercises due to some research indicating improvement may not be maintained over time. The core category was; ‘overcoming barriers to facilitate empowerment’, indicating that improving communication and education could reduce barriers and enable them to seek help.

To investigate the implementation and initial impact of the Physician Integrated Network (PIN) mental health indicators, which are specific to screening and managing follow-up for depression, in three primary care practices with Shared Mental Health Care in Manitoba.

Manitoba Health undertook a primary care renewal initiative in 2006 called the PIN, which included the development of mental health indicators specific to screening and managing follow-up for depression. These indicators were implemented in three PIN group practice sites in Manitoba, which are also part of Shared Mental Health Care.

The design was a non-experimental longitudinal design. A formative evaluation investigated the implementation and initial impact of the mental health indicators using mixed methods (document review, survey, and interview). Quantitative data was explored using descriptive and comparative statistics and a content and theme analysis of the qualitative interviews was conducted. Survey responses were received from 32 out of 36 physicians from the three sites. Interviews were conducted with 15 providers.

This evaluation illustrated providers’ perceived attitudes, knowledge, skills, and behaviours related to recognizing and treating depression and expanded our understanding of primary care processes related to managing depression related to the implementation of a new initiative. Depression is viewed as an important problem in primary care practice that is time consuming to diagnose, manage and treat and requires further investigation. Implementation of the PIN mental health indicators was variable across sites and providers. There was an increase in use of the indicators across time and a general sentiment that benefits of screening outweigh the costs; however, the benefit of screening for depression remains unclear. Consistent with current guidelines, a question the findings of this evaluation suggests is whether there are more effective ways of having an impact on depression within primary care than screening.

We aimed to evaluate a pilot service to facilitate discharge of patients with stable long-term mental health needs from secondary to primary care.

Patients with stable long-term mental health conditions are often not discharged from secondary mental health services when no longer needed due to insufficient systems and processes to enable safe, effective, recovery-focussed treatment and support. The Primary Care Mental Health Specialist (PCMHS) Service was developed to address this gap; new PCMHS posts were introduced to act as a conduit for patients being discharged from secondary care and a single point of referral back into secondary care, should it be required. The two-year pilot, across six Clinical Commissioning Groups in South East England, began in March 2013.

Interviews were conducted with all PCMHS employed in the pilot service (n=13) and a sample of service users (n=12). The views of professionals working alongside the service, including GPs, Psychiatrists and Mental Health Nurses, were captured using a brief online questionnaire (n=50). Time and Activity Recording Sheets were used to capture data required for economic analysis.

Our findings indicate that the service is working well from the perspective of patients; staff employed within the service and professionals working alongside the service. Patients described the service as a ‘safety net’ they could fall back on in case of difficulties, whereas staff used the analogy of a ‘bridge’ to describe the way the service improved communication and collaboration between the various professionals and organisations involved in the patient’s care. Improvements in well-being were seen to result from increased support for those transitioning from secondary to primary care, a more pro-active approach to relapse prevention and increased engagement in daily activities. Each PCMHS covered 36 patients in a one-month period, with a unit cost of £73.01 per patient.

To better understand barriers and facilitators that hinder or help women veterans discuss their alcohol use with providers in primary care in order to better identify problematic drinking and enhance provider–patient communication about harmful drinking.

Women presenting to primary care may be less likely than men to disclose potentially harmful alcohol use. No studies have qualitatively examined the perspectives of primary care providers about factors that affect accurate disclosure of alcohol use by women veterans during routine clinic visits.

Providers (n=14) were recruited from primary care at two veterans Administration Women’s Health Clinics in California, United States. An open-ended interview guide was developed from domains of the consolidated framework for implementation science. Interviews elicited primary care providers’ perspectives on barriers and facilitators to women veterans’ (who may or may not be using alcohol in harmful ways) disclosure of alcohol use during routine clinic visits. Interview data were analyzed deductively using a combination of template analysis and matrix analysis.

Participants reported six barriers and five facilitators that they perceived affect women veteran’s decision to accurately disclose alcohol use during screenings and openness to discussing harmful drinking with a primary care provider. The most commonly described barriers to disclosure were stigma, shame, and discomfort, and co-occuring mental health concerns, while building strong therapeutic relationships and using probes to ‘dig deeper’ were most often described as facilitators. Findings from this study may enhance provider–patient discussions about alcohol use and help primary care providers to better identify problematic drinking among women veterans, ultimately improving patient outcomes.

Most mid-life and older adults are not achieving recommended physical activity (PA) targets and effective interventions are needed to increase and maintain PA long-term for health benefits. The Pedometer And Consultation Evaluation (PACE-UP) trial, a three-armed primary care pedometer-based walking intervention in those aged 45–75 years, demonstrated increased PA levels at 12 months. A three-year follow-up was conducted to evaluate long-term PA maintenance, including a qualitative component.

To examine facilitators and barriers to PA maintenance in mid-life and older adults previously involved in a PA trial.

Semi-structured telephone interviews were conducted with 60 PACE-UP participants across all study arms. Interviews were audio-recorded, transcribed verbatim and coded independently by researchers, prior to thematic analysis.

Two-thirds of participants felt since the PACE-UP trial they had an awareness of PA, with the pedometer reported as ‘kick-starting’ regular activity, and then helped them to maintain regular activity. PA facilitators included: maintaining good health, self-motivation, social support and good weather. Lack of time was the most frequently cited barrier. Other barriers were often the inverse of the facilitators; for example, poor health and bad weather. Participants described the type of ‘top-up’ intervention they would find beneficial to aid PA maintenance (eg, text messages, online resources and walking groups).

A challenge for future PA interventions is to transform barriers into facilitators; for example, educating trial participants about the value of PA for many chronic health conditions to change this from inhibiting to promoting PA. Participants provided ideas for encouraging PA maintenance which could be incorporated into future interventions.

To compare the characteristics of mental health and physical health participants attending an exercise referral scheme (ERS) and investigate associations with their adherence to exercise.

While people referred to an ERS with a mental health diagnosis have similar initial rates of uptake as physical health participants, they are more likely to drop out. Comparisons of the groups to understand their differences and how these might impact on their adherence have been limited by the typically low numbers of mental health referrals in many schemes.

Retrospective analysis of a participant cohort. Data were extracted on all participants enrolled over a 12- month period (n = 701) and included measurements at baseline, mid-point (13 weeks) and end of programme (20-26 weeks). Differences were explored between the mental health (n=141) and physical health (n=560) subcohorts, and between adherers and non-adherers in each group. Binomial logistic regression estimated the effect of group-level factors associated with adherence.

Mental health referrals were more likely to be younger, White and unemployed, and had a lower mean body mass index and lower proportion of participants with high blood pressure. They were also more likely to drop out. While occupation was associated with exercise adherence among the physical health group, no predictive factors were identified in the mental health group.

Participants referred for mental health disorders are more likely to drop out of exercise referral schemes than those with physical health problems. While no factors were found to be predictive of their exercise adherence, an understanding of their distinguishing characteristics and attendance behaviour can guide in making better referral decisions concerning them and planning more appropriately tailored support.

To conduct an environmental scan of a rural primary care clinic to assess the feasibility of implementing an e-communications system between patients and clinic staff.

Increasing demands on healthcare require greater efficiencies in communications and services, particularly in rural areas. E-communications may improve clinic efficiency and delivery of healthcare but raises concerns about patient privacy and data security.

We conducted an environmental scan at one family health team clinic, a high-volume interdisciplinary primary care practice in rural southwestern Ontario, Canada, to determine the feasibility of implementing an e-communications system between its patients and staff. A total of 28 qualitative interviews were conducted (with six physicians, four phone nurses, four physicians’ nurses, five receptionists, one business office attendant, five patients, and three pharmacists who provide care to the clinic’s patients) along with quantitative surveys of 131 clinic patients.

Patients reported using the internet regularly for multiple purposes. Patients indicated they would use email to communicate with their family doctor for prescription refills (65% of respondents), appointment booking (63%), obtaining lab results (60%), and education (50%). Clinic staff expressed concerns about patient confidentiality and data security, the timeliness, complexity and responsibility of responses, and increased workload.

Clinic staff members are willing to use an e-communications system but clear guidelines are needed for successful adoption and to maintain privacy of patient health data. E-communications might improve access to and quality of care in rural primary care practices.