Primary care teams in Ireland: a qualitative mapping review of Irish grey and published literature

INTRODUCTION

The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland.

METHODS

This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository.

RESULTS

N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community.

CONCLUSION

There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.

Does eliminating fees at point of access affect Irish general practice attendance rates in the under 6 years old population? A cross sectional study at six general practices

With the introduction of free point of access GP care for children aged under six imminent, we sought to determine consultation rates among this group. We interrogated data from practice management systems at six general practices (total patient population 27080). A total of 1931 children aged under six were responsible for 5814 surgery consultations. The mean annual consultation rate was 3.01; 4.91 for GMS' patients, 5.07 for 'Doctor Visit' patients and 2.03 for private patients. Our findings suggest the introduction of free GP care for children under six will considerably increase GP consultations. We also highlight the value of routinely collected general practice data in facilitating health services planning. We estimate that there will be an additional 750,000 GP consultations annually.

Paediatric diabetes: information-seeking behaviours of families

The Internet provides patients and their families with ready access to on-line health related information. However, this information is not always accurate, understandable or provided by health professionals or advocacy groups. One hundred children with Type 1 diabetes mellitus, or their parents, attending a paediatric diabetes clinic during September to November 2011 were invited sequentially to participate in this questionnaire-based survey of Internet use in searching for diabetes-related information. Sixty-seven (67%) returned completed anonymised questionnaires: 36/67 (53%) were categorised as socio-economic groups C1/C2. Of the 67 families who returned completed questionnaires, 64 (96%) had a home computer and 62 (93%) had home Internet access; 27 (40%) rarely, and 40 (60%) frequently, searched on-line for diabetes-related information. Key search terms were not provided by respondents. There appears to be considerable internet use in seeking health related information for children with Type 1 diabetes mellitus. Clinicians should make efforts to direct patients and their families to websites that present accurate and current information.

Food and beverage advertising during children's television programming

BACKGROUND

Increasing prevalence of overweight and obese children in developed countries poses a substantial threat to long-term health. One well-described factor is the amount of time spent watching television, with exposure to food advertising a known influence on food preferences and consumption patterns.

AIMS

Following recent formulation of new rules regarding advertising of food during children's programming, we sought to examine the advertising content in children-specific television broadcasts on Irish television.

METHODS

Advertisement content analysis for 5 weekdays of children-specific television broadcasting from 0700 to 1700 hours on Irish television was performed. Data were coded and transferred to SPSS for analyses. Food and beverage advertisements were coded based on type of product, nutritional content, intended age group and outcome.

RESULTS

322 advertisements were broadcast during the recording period. 31 % (n = 101) of advertisements related to food or beverage products with 66.3 % (n = 68) of food advertisements being for foods that should be eaten in moderation. The most frequently recorded food advertisement was for fast food products (27.3 %, n = 24), followed by sweets/candy (21.6 %, n = 19) and dairy products (17.0 %, n = 15). The most frequently recorded beverage advertisement was for natural orange juices (46.2 %, n = 6). 54.7 % (n = 176) of advertisements were adult specific with 27.3 % (n = 88) being children specific. All food and beverage advertisements were associated with a positive outcome (n = 322).

CONCLUSIONS

These results demonstrate that food and beverages depicted in advertisements during children's programming are predominantly unhealthy foods with high salt and sugar contents. The findings from this study again highlight the ongoing need for new rules regarding food advertising in children's programming.

General practice career intentions among graduate-entry students: a cross-sectional study at Ireland's newest medical school

Increased care provision and clinical activity in General Practice in Ireland will have important manpower implications. Recent developments in medical education policy including the introduction of graduate-entry medical degree programmes may help address this issue. The aim of this study was to determine GP career intentions among students on an Irish graduate-entry medical degree programme and to identify factors that influence these. An electronic cross-sectional study of students at University of Limerick Graduate-Entry Medical School (UL-GEMS) was undertaken. We received 139 replies (78% response rate). 41 (29%) reported GP was their current preferred career choice, while 29 (19%) reported it was their preferred career choice on entry to medical school. This first study to present data on GP career intentions among graduate-entry students in Ireland highlights the specialty as a popular preferred career choice among students, both on entry to, and during medical school. The study also identifies factors which are likely to be important in determining career intentions. Further research to examine this issue at other graduate-entry medical schools in Ireland and to determine whether our findings are pursued over time amongst graduates is a priority.

Care of type 2 diabetes in unresourced general practice: current practice in the Mid-West

It is estimated that 4.5% of the Irish population have type 2 diabetes. The HSE intends to move the care of uncomplicated type 2 diabetes to General Practice (GP). The study reviewed current General Practice diabetes care in the Irish Mid-West. The files of randomly selected patients from 12 GP teaching practices attached to the University of Limerick were audited. 842 patients were identified (62% male, 38% female). The mean age was 66 years. 75% were GMS patients. A practice protocol was used in 71% of patients. Average Cholesterol (4.3 mmol/l), creatinine (85.3 mmol/l), HbA1c (56.7 mmol/mol) and systolic blood pressure (SBP) (134 mmHg) measurements were well documented and controlled. However the rates of and mean intervals for foot review (60.2%), BMI measurement (52.3%), retinopathy screening (62.0%) and influenza vaccination (63.0%) were unacceptably low. Current management of type 2 diabetes in unresourced general practices is suboptimal although some biochemical parameters are well controlled.

Are Irish adult general practice consultation rates as low as official records suggest? A cross sectional study at six general practices

Accurate data on primary care activity is key to health services planning and reconfiguration. Official data estimate general practice adult consultation rates to be 3.2 visits annually, based on patient self reports. We aim to estimate the consultation rate using practice based data and compare this to official estimates. We interrogated six general practices' information systems and estimated consultation rates based on practice, telephone, domiciliary and out of hours consultations by patients aged 18 years or older. The study population (20,706 patients) was representative of the national population in terms of age and GMS status. The mean consultation rate was 5.17, though this was higher among GMS-eligible patients and among older age groups. Estimates of consultation rates derived from practice based data are likely to be higher than that derived from other approaches. Using multiple sources of data will enhance accuracy of workload estimates and this will benefit service planning.

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

BACKGROUND

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

AIMS

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

METHODS

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified 'Delphi-facilitated' consensus among the group members.

RESULTS

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

CONCLUSIONS

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.

Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators

This qualitative study explored general practitioner's and practice nurse's perceptions of barriers and facilitators to the proposed transfer of diabetes care to general practice. Qualitative data were collected through five focus groups. Participants included GPs (n = 55) and practice nurses (n = 11) representing urban (44%), rural (29%) and mixed (27%) practices, in the Irish Mid-West region. Barriers and facilitators were mentioned 631 times (100%). Barriers were mentioned 461 times (73%), facilitators 170 times (27%). The most frequently identified barriers were lack of financial incentive (119/631; 19%), lack of access to secondary resources (93/631; 15%), lack of staff and increased workload (59/631; 9%) and time constraints (52/631; 8%). Identified facilitators were access to secondary care (49/631;7.8%), the holistic nature of general practice and continuity of care (48/631;7.6%). Although many are enthusiastic, there remains significant reluctance among GPs and practice nurses to take responsibility for diabetes care without addressing these barriers.

An evidence-based assessment of primary care needs in an economically deprived urban community

BACKGROUND

As healthcare and longevity improve and fertility rates decline, we see a demographic shift towards a predominantly elderly population. Because ageing brings its own physiological changes and complications, the need arises for practical and feasible approaches in providing the healthcare required by this population. With government strategy promoting enhanced community-based healthcare, the development of primary care infrastructure should reflect population needs.

AIMS

To describe the profile of older patients attending a general practice in an underprivileged urban setting, specifically initial medical presentation, referrals for secondary care, and the medicines prescribed to them. To thereby enhance our understanding of the primary care requirements of elderly people in this setting.

METHODS

The anonymised records of an older patient cohort (n=427, age>55 years) that presented to a General Practice over a 12-month period were retrospectively analysed to determine the nature of the clinical encounters, subsequent referral patterns and drugs prescribed.

RESULTS

There were 3,448 discrete clinical encounters (mean=8.0 per patient), predominantly for respiratory conditions, leading to 401 issued scripts and to 216 patients being referred for secondary care. Women were referred more often than men. There was a notable need for specialised dietary advice and drug prescribing was often complex.

CONCLUSION

This study provides evidence of primary care needs in an economically deprived area of an Irish city highlighting the complexity of associated prescribing and secondary care referrals in this setting.

Towards vertical integration in general practice education: literature review and discussion paper

BACKGROUND

Medical education policy in Ireland has enabled an increase in undergraduate and postgraduate education activity in general practice. Internationally, 'vertical integration in general practice education' is suggested as a key strategy to support the implementation of this policy development.

AIMS

To review the emerging literature on vertical integration in GP education, specifically to define the concept of 'vertical integration' with regard to education in general practice and to describe its benefits and challenges.

METHODS

We searched 'Pubmed', 'Academic Search Complete', 'Google', and 'MEDLINE' databases using multiple terms related to 'vertical integration' and 'general practice education' for relevant articles published since 2001. Discussion papers, reports, policy documents and position statements were identified from reference lists and retrieved through internet searches.

RESULTS

The key components of 'vertical integration' in GP education include continuous educational pathway, all stages in GP education, supporting the continuing educational/professional development needs of learners at each stage and effective curriculum planning and delivery. Many benefits (for GPs, learners and the community) and many challenges (for GPs/practices, learners and GPs in training) have been described. Characteristics of successful implementation include role sharing and collaborative organisational structures.

CONCLUSIONS

Recent developments in medical education in Ireland, such as the increase in medical school clinical placements in general practice and postgraduate GP training and the introduction of new competence assurance requirements offer an important opportunity to further inform how vertical integration can support increased educational activity in general practice. Describing this model, recognising its benefits and challenges and supporting its implementation in practice are priorities for medical education in Ireland.

Primary care support for youth mental health: a preliminary evidence base for Ireland's Mid-West

BACKGROUND

Mental and substance use disorders are leading causes of morbidity. Prevention/treatment amongst young people are global health priorities. International data have highlighted primary care and general practice as important in addressing these.

AIMS

Survey of 128 physicians (GPs) in Ireland's Mid-West (Counties Limerick, Clare, North Tipperary) to document the spectrum of youth mental health problems, describe strategies adopted by GPs in dealing with these, identify barriers (perceived by GPs) to effective care of young mental health patients and collate GP proposals for improved care of this cohort.

METHODS

Self-administered questionnaire on physician and practice demographics, case management and barriers to care in youth mental health.

RESULTS

Thirty-nine GPs (31 %) responded. Mental health and family conflict represented the most frequent reasons why young people attended GPs. Depression, anxiety, family conflict, suicidal thoughts/behaviour, and attention deficit hyperactivity disorder (ADHD) were the most common issues followed by substance abuse and antisocial behaviours. GP referral practices for young people with mental/substance use disorders varied, with distinctions between actual and preferred management due to insufficient access to dedicated youth services and training. GPs stated need for improved access to existing services (i.e., Psychiatry, counseling/psychology, social/educational interventions). A number of GPs surveyed were located, or provided care, in Limerick's 'Regeneration Areas'. Young people in these areas predominantly attended GPs due to mental/substance use issues and antenatal care, rather than acute or general medical problems.

CONCLUSIONS

GPs play an important role in meeting youth mental health needs in this region and, in particular, in economically deprived urban areas.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.