Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey

BACKGROUND

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities.

AIM

To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland.

DESIGN AND SETTING

In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken.

METHOD

Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI).

RESULTS

In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05).

CONCLUSION

Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Evaluation of myCOPD Digital Self-management Technology in a Remote and Rural Population: Real-world Feasibility Study

Background

Chronic obstructive pulmonary disease (COPD) is a common, costly, and incurable respiratory disease affecting 1.2 million people in the United Kingdom alone. Acute COPD exacerbations requiring hospitalization place significant demands on health services, and the incidence of COPD in poor, remote, and rural populations is up to twice that of cities.

Objective

myCOPD is a commercial, digital health, self-management technology designed to improve COPD outcomes and mitigate demands on health services. In this pragmatic real-world feasibility study, we aimed to evaluate myCOPD use and its clinical effectiveness at reducing hospitalizations, inpatient bed days, and other National Health Service (NHS) resource use.

Methods

myCOPD engagement and NHS resource use was monitored for up to 1 year after myCOPD activation and was compared against health service use in the year prior to activation. A total of 113 participants from predominantly remote and rural communities were recruited via community-based care settings, including scheduled home visits, outpatient appointments, pulmonary rehabilitation, and phone or group appointments. There were no predetermined age, disease severity, geographical, or socioeconomic inclusion or exclusion criteria.

Results

Out of 113 participants, 89 activated myCOPD (78.8%), with 56% (50/89) of those participants doing so on the day of enrollment and 90% (80/89) doing so within 1 month. There was no correlation between participant enrollment, activation, or myCOPD engagement and either age, socioeconomics, rurality, or COPD severity. Most active participants used at least one myCOPD module and entered their symptom scores at least once (79/89, 89%). A subgroup (15/89, 17%) recorded their symptom scores very frequently (>1 time every 5 days), 14 of whom (93%) also used four or five myCOPD modules. Overall, there were no differences in hospital admissions, inpatient bed days, or other health service use before or after myCOPD activation, apart from a modest increase in home visits. Subgroup analysis did, however, identify a trend toward reduced inpatient bed days and hospital admissions for those participants with very high myCOPD usage.

Conclusions

Our results suggest that neither age, wealth, nor geographical location represent significant barriers to using myCOPD. This finding may help mitigate perceived risks of increased health inequalities associated with the use of digital health technologies as part of routine care provision. Despite high levels of activation, myCOPD did not reduce overall demands on health services, such as hospital admissions or inpatient bed days. Subgroup analysis did, however, suggest that very high myCOPD usage was associated with a moderate reduction in NHS resource use. Thus, although our study does not support implementation of myCOPD to reduce health service demands on a population-wide basis, our results do indicate that highly engaged patients may derive benefits.

Health Literacy for Cardiac Rehabilitation: An Examination of Associated Illness Perceptions, Self-Efficacy, Motivation and Physical Activity

Following a diagnosis of cardiovascular disease there is a need for patients to self-manage. Health literacy has been shown to be lower in patients with cardiovascular disease, yet research into health literacy in this population is limited. This study used the Health Literacy Questionnaire (HLQ) to examine the health literacy and associated health, health behaviours and psychological profiles of cardiac rehabilitation patients from a remote and rural regional programme in the Scottish Highlands. Consecutive patients referred to the service in a calendar year were sent a cross-sectional questionnaire by post. Hierarchical cluster analysis grouped respondents based on their health literacy profile, and nonparametric methods were used to analyse differences between clusters on the other measures. A total of 282 participants responded (45.7%). Respondents were older (median: 71 years) and more likely to be from more affluent areas. Five health literacy clusters emerged with different profiles of health, physical activity, self-efficacy, motivation and illness perceptions. There was no difference in relation to cardiac rehabilitation attendance by health literacy cluster, but those with lower health literacy were less likely to be aware of the referral. Patterns of health literacy are associated with health, health behaviours and some psychological constructs. Knowledge of distinct cluster characteristics may help services better target interventions.

A cross-sectional survey of the perspectives of older people in the Scottish Highlands on the management of their chronic pain

BACKGROUND

Although there is evidence of suboptimal outcomes in older people with chronic pain, little emphasis has been placed on those in remote and rural settings.

OBJECTIVE

To describe the perspectives of older people in the Scottish Highlands on their chronic pain management.

DESIGN

Cross-sectional survey.

SETTING

NHS Highland, the most remote and rural geographical health board in Scotland.

SUBJECTS

Home-dwelling members of the public aged ≥70 years.

METHODS

Anonymised questionnaires were mailed to a random sample of 1800 older people. Questionnaire items were demographics, nature of any chronic pain, management regimens and perceived effectiveness. Validated scales were the Pain Disability Questionnaire and the Tampa Scale for Kinesiophobia.

RESULTS

Adjusted response rate was 39.3% (709/1755). One-quarter (25.0%, n = 177) were experiencing chronic pain, being more likely to live in deprived areas (P < 0.05). Median pain intensity was 6 (IQR 4-7, 10 high), causing distress (median 5, IQR 3-7). Respondents largely consulted GPs (66.1%, n = 117) with a minority (16.4%, n = 29) referred to a specialist pain clinic and few consulting other health professionals. Over three quarters (78.0%, n = 138) were receiving prescribed medicines, most commonly paracetamol, alone (35.6%, n = 63) or in combination with opioids (16.4%, n = 29). One-third (31.6%, n = 56) expressed a desire for more effective medicines; few reported using any non-pharmacological therapies. The median scores for the Pain Disability Questionnaire and Tampa Scale for Kinesiophobia were 74 (IQR 34-104.5, 150 high) and 40 (IQR 35-45, 68 high).

CONCLUSIONS

Evidence of provision of appropriate integrated and person-centred chronic pain care is lacking.

Assessing clinical support and inter-professional interactions among front-line primary care providers in remote communities in northern Canada: a pilot study

Background

Primary care in remote communities in northern Canada is delivered primarily by nurses who receive clinical support from physicians in regional centres and the patient transportation system. To improve continuity, quality and access to care in remote northern communities, it is important to understand the perspectives of front-line providers and the complex challenges they face.

Objective

To design and implement a survey of primary care providers to identify issues relating to inter-professional communication, clinical support and patient evacuation.

Methods

In collaboration with the territorial government and regional health authority partners, we developed a 21-item self-administered questionnaire survey, which could be completed online. The survey was sent to 218 physicians and nurses who were employed in the Northwest Territories (NWT) at the time of the survey and were involved in sending patients out of the community and/or receiving patients. The survey also contained an open-ended question at the end seeking comments regarding primary health care.

Results

The overall low response rate of 39% among nurses and 19% among physicians threatens the validity of the quantitative results. The majority of providers were satisfied with their ability to communicate with other providers in a timely manner, their freedom to make clinical decisions and their overall experience practicing in the NWT. The patient transfer system appears to work from both the sender and receiver perspectives. However, a common theme reported by nurses was that physicians providing clinical advice, especially short-term locums, were not familiar with the local situation, whilst physicians at the receiving end remarked that the clinical information provided to them often lacked clarity.

Conclusions

Important lessons were learnt from the pilot study, especially in better engagement of providers in planning and dissemination. The questionnaire design and the online method of delivery were acceptable. Although important issues were identified, a larger definitive survey is needed to investigate them in the future.

The impact of a support centre for people with sensory impairment living in rural Scotland

Aim The overall aim of this study was to evaluate whether attendance at a Sensory Support Centre for people with a sensory impairment living in the Western Isles of Scotland had an impact on their lives.

BACKGROUND

Demographic forecasts show that the prevalence of sensory impairment in the population will increase, as a significant proportion of sensory loss is age related. People with sensory impairments are more likely to experience social exclusion, and are more at risk of injury and physical and mental illness. Therefore, strategies to improve service access and provision for people with sensory impairments are important to reduce the disability associated with sight and/or hearing loss.

METHODS

All clients who accessed the service during a six-month period were invited to complete a postal questionnaire about their service experience. Semi-structured individual interviews with clients (n=12) described their experience of living with a sensory impairment and the impact (if any) that access to the Sensory Centre had on their lives. Individual interviews were also conducted with healthcare and social-care professionals (n=7) to ascertain their level of service awareness. Findings Clients who experienced sensory impairment described how the impairment negatively impacted on their activities of living, safety and independence. Following Sensory Centre assessment and support, some clients were able to identify ways in which interventions had reduced their sense of social isolation, impacted positively on self-confidence and sense of self-esteem and safety. Importantly, interventions had supported greater functional independence in their own homes.

CONCLUSION

This study provides evidence that access to sensory services are important to people with sensory impairments living in remote areas, and should be considered when planning healthcare services, as they are one way of ameliorating health inequalities in this population group.