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Pattani S, El Asmar ML, Karki M, Sasco ER, Shemtob L, Varghese K, El-Osta A. Embedding work coaches in GP practices: Findings from an interview-based study in the UK. PUBLIC HEALTH IN PRACTICE 2024; 8:100548. [PMID: 39381593 PMCID: PMC11460508 DOI: 10.1016/j.puhip.2024.100548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 10/10/2024] Open
Abstract
Background The integration of work coaches (WCs) and disability employment advisors (DEAs) into General Practitioner (GP) practices in the UK aims to address the interplay between health and employment by facilitating access to employment support, especially to people with disabilities and health conditions affecting their ability to work. This study seeks to explore the perspectives and perceptions of WCs, DEAs and GPs regarding the benefits and challenges of embedding WCs and DEAs in GP practices. Methods Data was collected between May and July 2023 through semi-structured interviews with four GPs, four WCs and four DEAs working in NHS GP practices. The interviews were audio-recorded, transcribed verbatim and thematically analysed using the Thematic Framework method. Emergent themes were pre-structured and classified as perceived benefits, barriers and challenges or drivers and strategies. Results The integration of WCs & DEAs within GP practices was perceived by respondents as fostering a direct collaboration between professionals as well as a greater openness of patients which benefited patients, WCs/DEAs and GPs. While all respondents emphasised the various benefits, they also identified several barriers and challenges. The implementation stage was perceived as particularly challenging, especially by WCs and DEAs, whereas the lack of human, financial and logistical resources hindered the service beyond this stage. Several strategies and drivers to support the service were identified, including the importance of receiving support from all professionals involved as well as making the service visible to both healthcare professionals and patients. Conclusion Embedding WCs and DEAs in GP practices emerges as a promising approach which can benefit patients, GPs and WCs/DEAs. Exploring patients' perspectives directly is crucial to fully assess this type of service and identify any additional challenges and benefits.
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Affiliation(s)
- Shriti Pattani
- Department of Primary Care & Public Health, Imperial College London, UK
| | - Marie Line El Asmar
- Self-Care Academic Research Unit (SCARU), Imperial College London School of Public Health, UK
| | - Manisha Karki
- Self-Care Academic Research Unit (SCARU), Imperial College London School of Public Health, UK
| | - Eva Riboli Sasco
- Self-Care Academic Research Unit (SCARU), Imperial College London School of Public Health, UK
| | - Lara Shemtob
- Imperial Occupational Health Group, Imperial College London School of Public Health, UK
| | - Kabir Varghese
- Department of Primary Care & Public Health, Imperial College London, UK
| | - Austen El-Osta
- Self-Care Academic Research Unit (SCARU), Imperial College London School of Public Health, UK
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Eder M, Henninger M, Durbin S, Iacocca MO, Martin A, Gottlieb LM, Lin JS. Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force. JAMA 2021; 326:1416-1428. [PMID: 34468710 DOI: 10.1001/jama.2021.12825] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Evidence-based guidance is limited on how clinicians should screen for social risk factors and which interventions related to these risk factors improve health outcomes. OBJECTIVE To describe research on screening and interventions for social risk factors to inform US Preventive Services Task Force considerations of the implications for its portfolio of recommendations. DATA SOURCES Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts (through 2018); Social Interventions Research and Evaluation Network evidence library (January 2019 through May 2021); surveillance through May 21, 2021; interviews with 17 key informants. STUDY SELECTION Individual-level and health care system-level interventions with a link to the health care system that addressed at least 1 of 7 social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, interpersonal safety, education, and financial strain. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data from studies and a second investigator evaluated data abstractions for completeness and accuracy; key informant interviews were recorded, transcribed, summarized, and integrated with evidence from the literature; narrative synthesis with supporting tables and figures. MAIN OUTCOMES AND MEASURES Validity of multidomain social risk screening tools; all outcomes reported for social risk-related interventions; challenges or unintended consequences of screening and interventions. RESULTS Many multidomain social risk screening tools have been developed, but they vary widely in their assessment of social risk and few have been validated. This technical brief identified 106 social risk intervention studies (N = 5 978 596). Of the interventions studied, 73 (69%; n = 127 598) addressed multiple social risk domains. The most frequently addressed domains were food insecurity (67/106 studies [63%], n = 141 797), financial strain (52/106 studies [49%], n = 111 962), and housing instability (63/106 studies [59%], n = 5 881 222). Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care. Thirty-eight studies (36%, n = 5 850 669) used an observational design with no comparator, and 19 studies (18%, n = 15 205) were randomized clinical trials. Health care utilization measures were the most commonly reported outcomes in the 68 studies with a comparator (38 studies [56%], n = 111 102). The literature and key informants described many perceived or potential challenges to implementation of social risk screening and interventions in health care. CONCLUSIONS AND RELEVANCE Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.
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Affiliation(s)
- Michelle Eder
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Michelle Henninger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Shauna Durbin
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Megan O Iacocca
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Allea Martin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Laura M Gottlieb
- Department of Family and Community Medicine, University of California, San Francisco
| | - Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Parry J, Vanstone M, Grignon M, Dunn JR. Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature. Int J Equity Health 2021; 20:219. [PMID: 34620188 PMCID: PMC8496150 DOI: 10.1186/s12939-021-01546-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it. PURPOSE OF STUDY This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation. METHODS Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes. RESULTS Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs. CONCLUSION Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.
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Affiliation(s)
- Jane Parry
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - Michel Grignon
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - James R. Dunn
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
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Beardon S, Woodhead C, Cooper S, Ingram E, Genn H, Raine R. International Evidence on the Impact of Health-Justice Partnerships: A Systematic Scoping Review. Public Health Rev 2021; 42:1603976. [PMID: 34168897 PMCID: PMC8113986 DOI: 10.3389/phrs.2021.1603976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Health-justice partnerships (HJPs) are collaborations between healthcare and legal services which support patients with social welfare issues such as welfare benefits, debt, housing, education and employment. HJPs exist across the world in a variety of forms and with diverse objectives. This review synthesizes the international evidence on the impacts of HJPs. Methods: A systematic scoping review of international literature was undertaken. A wide-ranging search was conducted across academic databases and grey literature sources, covering OECD countries from January 1995 to December 2018. Data from included publications were extracted and research quality was assessed. A narrative synthesis approach was used to analyze and present the results. Results: Reported objectives of HJPs related to: prevention of health and legal problems; access to legal assistance; health improvement; resolution of legal problems; improvement of patient care; support for healthcare services; addressing inequalities; and catalyzing systemic change. There is strong evidence that HJPs: improve access to legal assistance for people at risk of social and health disadvantage; positively influence material and social circumstances through resolution of legal problems; and improve mental wellbeing. A wide range of other positive impacts were identified for individuals, services and communities; the strength of evidence for each is summarized and discussed. Conclusion: HJPs are effective in tackling social welfare issues that affect the health of disadvantaged groups in society and can therefore form a key part of public health strategies to address inequalities.
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Affiliation(s)
- Sarah Beardon
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Charlotte Woodhead
- Department of Psychological Medicine, King's College London, London, United Kingdom
| | - Silvie Cooper
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Elizabeth Ingram
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Hazel Genn
- Faculty of Laws, University College London, London, United Kingdom
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, United Kingdom
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Beardon S, Woodhead C, Cooper S, Raine R, Genn H. Health-justice partnerships: innovation in service delivery to support mental health. JOURNAL OF PUBLIC MENTAL HEALTH 2020. [DOI: 10.1108/jpmh-03-2020-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to introduce the concept of “health-justice partnership” (HJP), the provision of legal assistance for social welfare issues in health-care settings. It discusses the role of these partnerships in supporting health and care for people with mental health issues.
Design/methodology/approach
The authors describe an example of an HJP; discuss the rationale and evidence for this approach in relation to mental health; and reflect on implementation challenges and future directions in the UK. The authors draw on both health and legal literature to frame the discussion.
Findings
Social welfare legal needs have negative impacts on mental well-being and are more likely to occur among people with mental health conditions. Integrating legal assistance with healthcare services can improve access to support for those with unmet need. High-quality research has demonstrated positive impacts for mental health and well-being as a result of HJP interventions. Both further research and wider strategies are required to support implementation of HJPs in practice.
Originality/value
Legal assistance is rarely positioned as a health intervention, yet it is an effective tool to address social welfare issues that are harmful to mental health and to which people experiencing mental health are at greater risk. This paper highlights the importance of the HJP movement as an approach for supporting people with mental health issues.
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Haighton C, Moffatt S, Howel D, Steer M, Becker F, Bryant A, Lawson S, McColl E, Vale L, Milne E, Aspray T, White M. Randomised controlled trial with economic and process evaluations of domiciliary welfare rights advice for socioeconomically disadvantaged older people recruited via primary health care (the Do-Well study). PUBLIC HEALTH RESEARCH 2019. [DOI: 10.3310/phr07030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWelfare rights advice services are effective at maximising previously unclaimed welfare benefits, but their impact on health has not been evaluated.ObjectiveTo establish the acceptability, cost-effectiveness and effect on health of a domiciliary welfare rights advice service targeting older people, compared with usual practice.DesignA pragmatic, individually randomised, parallel-group, single-blinded, wait-list controlled trial, with economic and process evaluations. Data were collected by interview at baseline and 24 months, and by self-completion questionnaire at 12 months. Qualitative interviews were undertaken with purposive samples of 50 trial participants and 17 professionals to explore the intervention’s acceptability and its perceived impacts.SettingParticipants’ homes in North East England, UK.ParticipantsA total of 755 volunteers aged ≥ 60 years, living in their own homes, fluent in English and not terminally ill, recruited from the registers of 17 general practices with an Index of Multiple Deprivation within the most deprived two-fifths of the distribution for England, and with no previous access to welfare rights advice services.InterventionsWelfare rights advice, comprising face-to-face consultations, active assistance with benefit claims and follow-up as required until no longer needed, delivered in participants’ own homes by a qualified welfare rights advisor. Control group participants received usual care until the 24-month follow-up, after which they received the intervention.Main outcome measuresThe primary outcome was health-related quality of life (HRQoL), assessed using the CASP-19 (Control, Autonomy, Self-realisation and Pleasure) score. The secondary outcomes included general health status, health behaviours, independence and hours per week of care, mortality and changes in financial status.ResultsA total of 755 out of 3912 (19%) general practice patients agreed to participate and were randomised (intervention,n = 381; control,n = 374). In the intervention group, 335 participants (88%) received the intervention. A total of 605 (80%) participants completed the 12-month follow-up and 562 (75%) completed the 24-month follow-up. Only 84 (22%) intervention group participants were awarded additional benefits. There was no significant difference in CASP-19 score between the intervention and control groups at 24 months [adjusted mean difference 0.3, 95% confidence interval (CI) –0.8 to 1.5], but a significant increase in hours of home care per week in the intervention group (adjusted difference 26.3 hours/week, 95% CI 0.8 to 56.1 hours/week). Exploratory analyses found a weak positive correlation between CASP-19 score and the amount of time since receipt of the benefit (0.39, 95% CI 0.16 to 0.58). The qualitative data suggest that the intervention was acceptable and that receipt of additional benefits was perceived by participants and professionals as having had a positive impact on health and quality of life. The mean cost was £44 per participant, the incremental mean health gain was 0.009 quality-adjusted life-years (QALYs) (95% CI –0.038 to 0.055 QALYs) and the incremental cost-effectiveness ratio was £1914 per QALY gained.ConclusionsThe trial did not provide sufficient evidence to support domiciliary welfare rights advice as a means of promoting health among older people, but it yielded qualitative findings that suggest important impacts on HRQoL. The intervention needs to be better targeted to those most likely to benefit.Future workFurther follow-up of the trial could identify whether or not outcomes diverge among intervention and control groups over time. Research is needed to better understand how to target welfare rights advice to those most in need.Trial registrationCurrent Controlled Trials ISRCTN37380518.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 3. See the NIHR Journals Library website for further project information. The authors also received a grant of £28,000 from the North East Strategic Health Authority in 2012 to cover the costs of intervention delivery and training as well as other non-research costs of the study.
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Affiliation(s)
- Catherine Haighton
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Suzanne Moffatt
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mel Steer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Frauke Becker
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Lawson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eugene Milne
- Public Health Directorate, Newcastle City Council, Newcastle upon Tyne, UK
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
- Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Terry Aspray
- Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Martin White
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
- Medical Research Council (MRC) Epidemiology Unit, University of Cambridge, Cambridge, UK
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Woodhead C, Collins H, Lomas R, Raine R. Co-located welfare advice in general practice: A realist qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:1794-1804. [PMID: 28569395 DOI: 10.1111/hsc.12453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 06/07/2023]
Abstract
General practitioners (GPs) engage with patients about a variety of social issues distinct from direct clinical work ("non-health" issues), such as health-related benefits and debt. Co-located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co-located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty-four semi-structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non-health work on practices: reduction of GP consultations linked to non-health issues and reduced practice time spent on non-health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre-existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the "go-to-location". We conclude that co-location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co-location to meet desired objectives.
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Affiliation(s)
- Charlotte Woodhead
- Department of Applied Health Research, University College London, London, UK
| | - Hillliary Collins
- Department of Applied Health Research, University College London, London, UK
| | | | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
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Allmark P, Baxter S, Goyder E, Guillaume L, Crofton-Martin G. Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways. HEALTH & SOCIAL CARE IN THE COMMUNITY 2013; 21:59-68. [PMID: 23039788 PMCID: PMC3557712 DOI: 10.1111/j.1365-2524.2012.01087.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/27/2012] [Indexed: 06/01/2023]
Abstract
Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.
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Affiliation(s)
- Peter Allmark
- Health and Social Care Research Centre, Sheffield Hallam University, UK.
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Evaluation of welfare advice in primary care: effect on practice workload and prescribing for mental health. Prim Health Care Res Dev 2012; 14:307-14. [PMID: 23046829 DOI: 10.1017/s1463423612000461] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIMS To determine Citizen's Advice Bureaux (CAB) and general practice staff perceptions on the impact of a CAB Health Outreach (CABHO) service on staff workload. To quantify the frequency of mental health issues among patients referred to the CABHO service. To measure any impact of the CABHO service on appointments, referrals and prescribing for mental health. BACKGROUND GPs and practice managers perceive that welfare rights services, provided by CAB, reduce practice staff workload, but this has not been quantified. METHODS Interviews with practice managers and GPs hosting and CAB staff providing an advisory service in nine general practices. Comparison of frequency of GP and nurse appointments, mental health referrals and prescriptions for hypnotics/anxiolytics and antidepressants issued before and after referral to the CABHO service, obtained from medical records of referred patients. FINDINGS Most GPs and CAB staff perceived the service reduced practice staff workload, although practice managers were less certain. CAB staff believed that many patients referred to them had mental health issues. Data were obtained for 148/250 referrals of whom 46% may have had a mental health issue. There were statistically significant reductions in the number of GP appointments and prescriptions for hypnotics/anxiolytics during the six months after referral to CABHO compared with six months before. There were also non-significant reductions in nurse appointments and prescriptions for antidepressants, but no change in appointments or referrals for mental health problems. The quantitative findings therefore confirmed perceptions among both CAB and practice staff of reduced workload and in addition suggest that prescribing may be reduced, although further larger-scale studies are required to confirm this.
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