Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review

INTRODUCTION

Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?"

METHOD

Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data.

RESULTS

Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP.

CONCLUSION

Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.

Medical Students' Knowledge and Attitudes TowardsUniversal Access to Healthcare (UHC) Systems

Aim With the introduction of universal access to healthcare central to health policy in Ireland, this study aims to examine the attitudes of medical students to the implementation of such policy. Methods A cross sectional study of final year students on the MB degree programme at UCD School of Medicine was conducted. Students were asked to indicate the extent with which they agreed / disagreed with several statements using a Likert-scale (where 1=strongly disagree and 5=strongly agree). Results A total of 98(42%) of the 236 final year students completed the survey. The statements with which respondents most agreed were: "the GP's workload would increase" and "a UHC system is preferable to one in which only some patients have free access to certain services" (mean 4.3, SD 0.85 and mean 3.85, SD 1.05, respectively). The statements with which students most disagreed were: "it would be straightforward to introduce such a system in the practice(s) in which I have been on placement" and "under a UHC model, patients would receive quicker care" (mean 2.14, SD 0.91 and mean 2.29, SD 1.09 respectively). Conclusion The findings suggest that medical students are positively disposed to the introduction of UHC but have concerns regarding workload.

Irish Defence Forces combat medical technician training: experience of a novel university medical school-based programme

AIMS

This study explores the opinions and experiences of Irish Defences Forces' (IDF) graduates from University College Dublin's Diploma in Military Medicine Care (DMMC). It aims to identify which aspects of medical education are relevant for the development of military graduates in the role of Combat Medical Technician (CMT) in future.

METHODS

A validated Clinical Learning Environment Score tool was adapted and incorporated into an online survey. This was sent electronically to 71 graduates. Responses were anonymous.

RESULTS

38 (54%) graduates responded. Student feedback was positive regarding teaching and clinical placements in the DMMC. In total 16 (42%) students reported use of their new skills in their daily work. Of the 9 (24%) deployed overseas, all used their new skills. Emergency and occupational health skills were used more frequently, while advanced skills were used rarely.

CONCLUSION

An increased emphasis on frequently used skills should be considered. Links to healthcare services would be of benefit to graduates in skills maintenance. Key advanced skills, such as intravenous cannulation and advanced airway management are rarely used but mechanisms to maintain them will improve the relevance of the programme to the CMT role. A change in how the IDF acknowledges qualifications may support more graduates in advancing and maintaining their career in the military medical workforce.

Opiate use disorders and overdose: Medical students' experiences, satisfaction with learning, and attitudes toward community naloxone provision

INTRODUCTION

Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment.

METHODS

We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees.

RESULTS

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

CONCLUSIONS

Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

The MERIT 3 project: Alerting general practitioners to cardiac arrest in the community

BACKGROUND

The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events.

AIM

To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities.

METHODS

GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the 'MERIT 3' project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry.

RESULTS

423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors.

CONCLUSION

Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Advisory External Defibrillator Availability in General Practice

This study aimed to describe the availability of advisory external defibrillators (AEDs) in Irish General Practice. The study utilised a computer generated random sample of Irish general practitioners and involved a postal questionnaire, with telephone follow up of non-responders. The cohort of GPs already known to possess an AED (via participation in the Merit Project) was excluded. 115 valid paper survey responses were received representing a response rate of 59%. 5 of the responding GPs identified themselves as Merit project participants and were excluded from data analysis. 74/110 GPs (67%) reported having one or more AED(s) available for use at their practice. 41/77 GPs (53%) who had not responded to the paper survey but were contactable by telephone had an AED available. When AED availability was examined by practice setting a higher proportion of rural and mixed settings had AEDs available than in urban and city areas. Cost was reported as the most common reason for not having an AED.

Immediate care training in Ireland, 2002-2013: a potential link between high uptake rates and effect

Recent data suggest GPs contribute to successful resuscitation of cardiac arrests in the community. This paper examines uptake of Immediate Care training by GPs over a 12 year period. Data was collated on all courses and attenders (2002-2013). 244 cardiac, trauma and paediatric courses were held with 4247 attendances by 2069 individuals, including 1790 (86.5%) doctors. Of these 1648 (92.1% of all doctors) were GPs or GP registrars who generated 3585 days of attendance (84.4% of the total); 1270 attended more than one course. Between 2006 and 2013, an average of 219 (range 186-261) GPs/GP registrars attended at least one course each year, representing around 8% of all GPs in Ireland. A subset of these GPs has been shown to have a significant success rate in cardiac arrest care; there may be links between uptake of training and the clinical effectiveness of care provided.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland

BACKGROUND

More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities.

AIM

To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings.

METHODS

The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition.

RESULTS

1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)).

CONCLUSION

There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.

Socio-economic gradients in self-reported health in Ireland and Northern Ireland

BACKGROUND

Research and policy related to reducing health inequalities has progressed separately within Ireland and Northern Ireland. This paper describes the first exploration of the socio-economic influences on health on the island of Ireland since 1922.

METHODS

Postal survey.

RESULTS

The response rate was 52%; 11,870 respondents. Men reported more long-standing illness (LLTI) or poor general health (PGH); depression was more common amongst women. Socio-economic gradients in health were evident in both jurisdictions, with the effects of household income being particularly marked. Overall, morbidity levels were significantly better in Ireland than in Northern Ireland: adjusted odds ratio of 0.79 (95% CI 0.71 - 0.88) for LLTI; 0.64 (0.57 - 0.72) for PGH; 0.90 (0.82 - 0.99) for depression.

CONCLUSIONS

There is evidence of strong and similar socio-economic gradients in health throughout the island of Ireland. This would suggest joint policy approaches or at least further comparative evaluation of the initiatives in each jurisdiction.

Cardiac arrest management in general practice in Ireland: a 5-year cross-sectional study

OBJECTIVE

To document the involvement of general practitioners (GPs) in cardiac arrests with resuscitation attempts (CARAs) and to describe the outcomes.

DESIGN

A 5-year prospective cross-sectional study of GPs in Ireland equipped with automated external defibrillators (AEDs) and immediate care training by the MERIT Project, with data collection every 3 months over the 5-year period. Practices reported CARAs by quarterly survey with an 89% mean response rate (81-97% for the period).

SETTING

General practices throughout Ireland.

PARTICIPANTS

495 GP participated: 168 (33.9%) urban, 163 (32.9%) rural and 164 (33.1%) mixed.

INTERVENTIONS

All participating practices received a standard AED and basic life support kit. Training in immediate care was provided for at least one GP in the practice.

MAIN OUTCOME MEASURES

Incidence of CARA in participating practices. Return of spontaneous circulation (ROSC) and discharge alive from hospital.

RESULTS

36% of practices were involved in a CARA during the 5-year period and 13% were involved in more than one CARA. Of the 272 CARAs reported, ROSC occurred in 32% (87/272) and discharge from hospital in 18.7% (49/262). In 45% of cases, the first AED was brought by the GP and in 65%, the GP arrived before the ambulance service. More cases occurred in rural and mixed settings than urban ones, but the survival rates did not differ between areas. In 65% of cases, the GP was on duty at the time of the incident and 47% of cases occurred in the patient's home.

CONCLUSIONS

These outcomes are comparable with more highly structured components of the emergency response system and indicate that GPs have an important role to play in the care of patients in their own communities. GPs experience cardiac arrest cases during the course of their daily work and provide prompt care which results in successful outcomes in urban, mixed and rural settings.

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.

Determinants of partial or no primary immunisations

OBJECTIVE

To determine if different factors affect children having full, partial or no primary immunisations.

METHODS

This was a crossgenerational cohort study with linkage to primary care and hospital records conducted in urban and rural settings in Ireland, recruiting in 2001-2003 with 5-year follow-up. A total of 749 children with immunisation information took part.

RESULTS

The uptake of reported primary immunisations was 92.8% full, 4.9% partial and 2.3% no primary immunisations. Adjusted relative risk ratios for children receiving no primary immunisations were significant for: having a mother who had ever visited an alternative practitioner 3.69 (1.05 to 12.9), a mother with means tested full general medical services eligibility 8.11 (1.58 to 41.65), a mother who scored <50 for the World Health Organization Quality of Life (WHO-QOL) scale psychological domain 8.82 (1.79 to 43.6) or living in the west of Ireland (rural) 3.64 (1.0 to 13.2). Being born prematurely was associated with partial primary immunisation, adjusted OR 4.63 (1.24 to 17.3).

CONCLUSIONS

Knowledge of these differences will help target campaigns to increase full uptake of primary immunisations.

A primary care-based health needs assessment in inner city Dublin

BACKGROUND

In 2001, a primary care-based health needs assessment (HNA) in South Inner City of Dublin identified high levels of morbidity and widespread and frequent use of primary care and specialist hospital services as particular concerns.

AIMS

This study aims to determine the primary care health needs of a local community, from the perspective of service users and service providers.

METHODS

A similar methodology to our 2001 HNA was adopted, involving semi-structured interviews with a convenience sample of patients attending two general practices and key informants regarding local health issues and health service utilisation.

RESULTS

High levels of morbidity and chronic illness were found. A correlation between the local environment and ill-health was identified, as well as high utilisation of primary care services in the area.

CONCLUSION

The establishment of a Primary Care Team would begin to address the health needs of the community.

Experience of prehospital emergency care among general practitioners in Ireland

BACKGROUND

Although widely acknowledged, few data exist on the scope of general practice involvement in the management of prehospital emergencies. A study was undertaken to explore the frequency and types of emergencies dealt with and the interventions undertaken by GPs who had completed Immediate Care training.

METHODS

All participants in Immediate Care courses in Ireland in 2002, 2003 and 2004 were invited to complete an anonymised questionnaire in which they estimated their experience of emergencies since completing a course. Sections dealt with personal/practice information, types of emergencies, interventions used and follow-up training.

RESULTS

448 participants completed courses, 408 were available to participate in the study and 259 (63.5%) responded; 66.6% of GPs responded. The mean reporting period was 29.4 months (range 18-53). Participants included many younger female GPs at the start of their general practice careers. Although most emergencies dealt with were medical, few other patterns emerged in the timing or setting of emergencies. 88% of GPs had called an ambulance in an emergency at least once in the preceding year. 84% of GPs had managed a suspected acute myocardial infarction at least once during the reporting period; seizures, serious injuries, paediatric emergencies and hypoglycaemia were dealt with by up to half of all GPs. Interventions used included intravenous access in a medical emergency (69%), intravenous fluid administration (51%), intravenous morphine (54%), cardiopulmonary resuscitation (37%), defibrillation (21%), use of airway adjuncts (28%) and use of advanced life support drugs in cardiac arrest (24%).

CONCLUSIONS

GPs make frequent use of a wide range of interventions in prehospital emergencies. Issues relating to tailored training, adequate equipment, collaboration with the emergency services and skills maintenance are highlighted by these data.

Primary care utilisation rates in pre-school children

A key objective of the Lifeways cross generation cohort study is to examine health and healthcare, according to socio-economic indicators, during the first five years of life. GP contact details were available for 1032 children. 772 GPs in 589 practices were approached and data were obtained on 640 children (59% of original cohort). The mean follow-up time was 3.0 years (95% CI 2.5-3.5). 20.5% of children had a medical card. The mean GP consultation rate was 5.5 visits per child per year, 6.6 visits for children with a medical card and 5.1 for those without (95% CI 1.1 to 1.9) p = 0.001. 68 had a diagnosis of asthma; 19.10% with a medical card and 8.9% without (95% CI 3.0-17.5) p = 0.0001. 138 children had ever been admitted to hospital; 26.2% with a medical card and 21.0% without (95% CI -3.3% to 13.6%) p = 0.2. Incremental increases in parental income significantly decreased both the risk of asthma (p = 0.02) or hospital admission (p = 0.008).

The risk factor profile of grandparents

In the Lifeways Cross Generation Cohort Study, mothers were asked to recruit at least one of 4 potential living grandparents to the study, and 1177 grandparents became active participants who either completed a health status questionnaire only (n = 707), or subsequently underwent a cardiovascular risk assessment examination at home (n = 958). Mean age of grandfathers at baseline was 61.5 years (SD 10.3), of grandmothers 59.2 years (SD 9.1), with a range of 40-83 years, 21% of grandmothers and 16% of grandfathers were third level educated. Risk factor profile of grandparents tended to be more adverse than the general population as assessed by the standard cardiovascular risk factor SCORE. Grandparents' socio-demographic characteristics were similar, whether maternal or paternal in origin. Predictors of positive self-rated health were non smoking (OR 1.5, p = 0.06) and non GMS eligibility (OR 1.99, p < 0.001). At four year follow-up, complete general practice data were available for 285 of 488 respondents with full recruitment data (58.4%). Increased GP utilisation pattern was predicted by baseline morbidity characteristics, though heavier male drinkers were less likely to attend.

Dietary habits of pregnant women in Ireland

This analysis of the Lifeways Cohort study mothers during pregnancy (n = 1124), utilises information from a standard food frequency questionnaire completed at baseline recruitment during early pregnancy. We demonstrate that 76% of women achieved recommended intakes of 5 plus portions of fruit and vegetables daily, though this is strongly socially patterned, inversely associated with age and positively associated with level of education. Achievement of the other recommended shelf intakes of the Food Pyramid is much lower, ranging from 12% achieving the recommended sparing intake of foods high in fat, salt or sugar, to 45% consuming the recommended 3 portions per day of meat and poultry. General medical services eligible respondents are generally less likely to achieve recommended intakes. While 61% of women under 25 years old stopped drinking during pregnancy, this dropped to 38% of expectant mothers over 35 years. Less than half (45%) of those (n = 860) who responded specifically to the question reported peri-conceptual folate supplement intake, again strongly socially patterned. These findings both provide important prevalence data and highlight the need for more concerted and supportive health promotion interventions during pregnancy.

Self-reported pre-pregnancy maternal body mass index and infant birth-weight

This analysis examines the association between maternal characteristics, particularly body mass index (BMI) and infant birth weight in 1048 live infants. Mean reported pre pregnancy BMI of mothers was 23.74 kg/m2 (SD 4.21). The educational level of the mother's parents was independently associated with maternal BMI, those with higher educated parents having a lower reported BMI (F = 2.787, p = 0.029). Mean infant birth weight was 3493 g (SD 18.1) and there was a strong graduated relationship to estimated gestational age. In a sub-group of participating maternal grandmothers (n = 171), reported BMI was 26.7Kg/m2. The BMI of expectant mothers was significantly associated with their own mother's BMI. (r = 0.179, p = 0.005) in this sub-group. These preliminary findings, which will be investigated further with recorded height and weight information, suggest that familial factors are influential, perhaps through genetic predisposition or shared socio-cultural factors such as diet.

Mothers' dietary patterns during pregnancy and risk of asthma symptoms in children at 3 years

There is increasing evidence that dietary factors in early life play a role in the aetiology of childhood asthma. Our objective in this analysis was to assess whether maternal dietary patterns during pregnancy, as measured by a validated food frequency questionnaire, influenced general practitioner diagnosis of asthma by the age of 3 years in the Life-ways cohort of children. General Practice follow-up records were available for 631 of 1001 singleton children, twins having been excluded (63% follow-up rate). Overall 10.4% of children had diagnosed asthma, a prevalence rate comparable with other studies. In logistic regression models, based on quartiles of intake, which adjusted for maternal lifestyle and socio-economic circumstances, relatively higher maternal fruit and vegetable intake and oily fish consumption were associated with lower risk of children developing asthma, whilst those with relatively higher spreadable fat intake had a higher risk of asthma. These findings warrant further investigation as they imply an important role for maternal diet in childhood asthma, though the confounding effect of other social and lifestyle factors should be assessed as the children get older.

Socio-demographic, lifestyle and cross-generation predictors of self-rated health in mothers during pregnancy

The Lifeways Cross-generation study was established to assess the influence of socio-economic and familial characteristics on the health status and early development of children. Between October 2001 and June 2002, 1124 women were recruited to the Lifeways study at booking or first visit to maternity hospital. Lifeways mothers were 29.4 (SD 5.9) years old at recruitment, two-thirds from greater Dublin area, 17.9% held a General Medical Services (GMS) card, 64.3% were married and 40.8% were third level educated. At uni-variate level, GMS eligibility, own and parents' education and marital status all predicted mother's self rated health during pregnancy, whilst in the final multivariate logistic regression model, GMS status, household-adjusted income, marital status and grand-maternal education were each independently predictors. The Lifeways cohort confirms the importance of social position in predicting health in pregnant Irish women.

Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems

Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than in NI (69.2% and 57.0% respectively) Less than 1 in 10 patients in ROI waited two or more working days to see a doctor of choice (8.1%) compared to almost half (45.0%) in NI. In NI overall satisfaction decreased as practice size increased; 82.8%, 80.4%, and 75.8%. In both systems, in large practices, accessibility is reduced when compared to smaller practices. The faster access to GP services in ROI may be due to the deterrent effect of the consultation charge freeing up services although, as it is the poorest and sickest who are deterred by the charge this improved accessibility may come at a significant cost in terms of equity. The underlying concern for policy makers centres around provision of equitable services.

The introduction of graduate entry medical programmes: potential benefits and likely challenges

There have been moves to introduce graduate entry programmes at medical schools both internationally and nationally. This, paper aims to review the recent literature on this policy issue and to discuss its implications in the context of the proposed introduction of graduate entry programmes at medical schools in Ireland. A number of potential advantages to this policy have been described, including: better educational outcomes, increased student motivation, benefits to student wellbeing, increased diversity of the student body, improved student learning strategies and improved professional outcomes. An equal number of challenges associated with this policy have also been described, including: increased stress levels for students, increased difficulties establishing an equitable admissions process, challenges to the curriculum to accommodate students with different educational backgrounds and other organisational issues. These issues must be considered in the transition to graduate entry programmes at medical schools in Ireland. The introduction of graduate entry programmes at medical schools in Ireland represents an important opportunity to inform the international debate on this subject.

EMTs and GPs: what do we think of each other?

BACKGROUND

Ireland's health services are undergoing dramatic reorganisation. The establishment of general practitioner (GP) out of hours cooperatives and the integration of current ambulance services into a national ambulance service are among the issues that will impact on prehospital care of emergencies. The study aimed to explore the perceptions of GPs and emergency medical technicians (EMTs) of their own and each other's roles in the context of such reforms.

METHODS

A census of all GPs (511) and EMTs (301) in three of Ireland's eight health board regions was undertaken. A questionnaire containing 31 statements asked respondents to indicate their agreement (or lack of it) in areas such as general relationships, care, and training, roles in emergencies and future developments.

RESULTS

Of the personnel contacted, 72% of GPs and 75% of EMTs responded. They report excellent working relationships, agree that the ambulance service is of high quality, and that GPs are willing to provide care in emergencies. However, working links are less satisfactory for EMTs, who report a far higher perception of GP use of emergency ambulances than reported by GPs. Both groups are interested in innovative future links.

DISCUSSION

Convergence between the professional groups in different geographic areas and between the disciplines across the areas is striking. They include areas of satisfaction and dissatisfaction. The need for improved liaison between the disciplines is clear.

General practice out-of-hours co-operatives--population contact rates

Since 1998, Irish general practice has developed 11 out-of-hours co-operatives, covering almost 40% of the population. The co-operatives vary in terms of triage mechanisms, treatment centres and domiciliary visits. Out-of-hours consultation rates for the GMS sector of the population (one-third of the population who receive free primary care on the basis of low income) have increased rapidly to 438 consultations/1000 persons/year by 2003. British and Danish out-of-hours co-operatives report annual contact rates of 280-470 contacts/1000 persons per year. The aims were to describe 12 month activity data in the co-operatives and to describe the workload in the context of the population served. A questionnaire survey for a 12 month period was completed by all 11 co-operatives. The results were that almost 340,000 contacts occurred during the period, with 34.0% dealt with by phone advice alone, 53.8% dealt with by visits to treatment centres and 12.3% dealt with by domiciliary visits. The mean population contact rate is 221 contacts/1000 persons/year (range 370-70) and the mean consultation rate is 144 consultations/1000 persons/year. Two distinct bands of contact rates emerged - seven of eight rural co-operatives (all with domiciliary services) have a range of 220-300 contacts/1000 persons/year while three urban co-operatives (none of which have integrated domiciliary services) have a range of 70-90 contacts/1000 persons/year. These results are explored in the context of UK and Danish data, with which they compare. The implications of the urban/rural banding are significant and require early further research.

Accreditation of medical schools in Ireland: standards and procedures

The Irish Medical Council has undertaken accreditation inspections of Irish medical schools on a regular basis since 1996. This document is a summary of the accreditation standards, a guide to the process for those involved and an overview of the complexity of the many elements involved in educating a doctor. It should be read in conjunction with previous Medical Council publications on medical education. It also provides the basis for the Evaluation System for Visitors 2003. The Medial Council's prime role is the protection of the public interest in relation to the practice of medicine. The Medical Council scrutinises medical schools. It has an important advocacy role with government, with the universities which operate medical schools and with the professionals involved to improve the standards and delivery of medical education.

General practice out-of-hours co-operatives in Ireland — emergency service or not?

BACKGROUND

Since 1998, Irish general practice has developed 11 out-of-hours co-operatives, covering almost 40% of the population.The co-operatives vary in terms of triage mechanisms, treatment centres and domiciliary visits but no data exist on their role in the management of emergencies in the community.

AIMS

To describe the role of co-operatives in the management of emergencies, both in quantitative and qualitative terms.

METHOD

A questionnaire survey for a 12-month period completed by all 11 co-operatives described structures and activity levels. Semi-structured interviews with senior management and GPs at five randomly selected co-operatives explored their understanding of the role of co-operatives.

RESULTS

The incidence of emergencies is very variable (10% of all contacts-virtually nil) with general reliance on the skills of triage staff rather than use of protocols to identify emergencies. Eight of 11 co-operatives provide a domiciliary service with some responding to calls from ambulance services and Gardai for medical assistance. There are very limited liaison structures with ambulance services at any level. Interviews with staff reveal concern with a perceived role as a service dealing with 999 type calls rather than with emergencies encountered in the course of normal general practice work.

CONCLUSIONS

Clarification is urgently required of the extent to which GP co-operatives and ambulance services support each other. Examples include procedures for passing calls between services, mutual understanding of each others roles and development of common procedures.

Guidelines for the management of hepatitis C in general practice: a semi-qualitative interview survey of GPs’ views regarding content and implementation

BACKGROUND

Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment.

AIM

To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation.

METHODS

A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines.

RESULTS

GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation.

CONCLUSIONS

Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.