Honiton Hospital

This article is Open Access: CC BY 4.0 licence (http://creativecommons.org/licences/by/4.0/).

GPs were a key driving force for the development of a network of community hospitals across England, and have provided medical cover for most of them. However, during the past decade there has been a significant shift, with the dominant trend appearing to be one of declining GP involvement. To explore how and why the role of GPs within community hospitals in England is changing. Qualitative study in a sample of nine diverse community hospitals in England. Qualitative interviews with community hospital clinical staff. In all, 20 interviews were conducted and two models of medical care observed: GPs employed by a practice and trust-employed doctors. Interviewees confirmed the trend towards declining GP involvement, with the factors driving change identified as being GP workload and recruitment challenges, a change from 'step-up' admissions from the community to 'step-down' admissions from acute hospitals, fewer local patients being admitted, increased medical acuity of patients admitted, increased burden of medical support required, and inadequate remuneration. The majority of doctors viewed community hospital work in a positive light, welcoming the opportunities for personal development and to acquire new clinical skills. GPs viewed community hospital work as an extension of primary care, adding to job satisfaction. Multiple factors have driven changes in the role of GP community hospital clinicians. The NHS needs to develop a focused strategy if GPs are to remain engaged with community hospital work.

It was very pleasing to see a paper reporting a pilot study of primary care endometrial sampling1as this was something I have been involved with over the last 25 years. However, I was a little disappointed that there was no reference to some of the previous work on this subject in primary care.2 I published two papers on this subject in 1998. The first considered the end of the operation of dilatation and …

In short, there isn’t anything stopping you from scaling. In this chapter, we’re going to see exactly how to start scaling, as well as why scaling becomes exponential—meaning the the more you scale, the more you find ways to scale in future. The biggest roadblock stopping us from scaling, though, is often seen as money.

The Story of Pain: From Prayer To Painkillers Joanna Bourke Oxford University Press, 2014 HB, 416pp, £20.00, 978-0-19-968942-2 Joanna Bourke, Professor of History at Birkbeck College, presents an in-depth analysis of the language of pain and its interpretation by sufferers and clinicians drawn from Western literature of the past three centuries. This book is not a physiological description of pain or a handbook of pain control. Who is it for? Anyone wanting a deeper understanding of pain and its meaning for them and their patients, for those …

ObjectiveTo explore how bereaved family members recall managing end of life medications when delivering care to a patient dying at home in England.DesignQualitative study.SettingDomestic homes in two contrasting areas in England.Participants59 bereaved family carers who have delivered care to a patient who spent a minimum of 2 weeks at home prior to their death from cancer or other non-malignant condition. Cases were excluded if the place of death was: a hospice, nursing home or National Health Service (NHS) hospital.ResultsParticipants identified a number of important concerns about managing end of life medication for the dying person at home. Although some support with medications is provided by general practitioners and nurses in the community, family carers take primary responsibility for drug administration and storage. They reported anxiety about giving correct and timely dosages, and concerns about keeping the patient comfortable without overdosing them or risking shortening their lives. In particular, they reported that certain analgesic medications, especially opioids, were considered to have a symbolic significance increasing analgesia requirements, and the use of a syringe driver was associated with deterioration and approaching death. Key barriers to managing end of life medications at home included: complex regimes; unwanted responsibility in deciding when to use ‘as needed’ medication; disagreements with professional staff, and anxiety about medication errors, especially if perceived to have implications for survival.ConclusionsFamily carers require more information about end of life drugs and their effects, support and training in managing medication for a dying person.

PurposeThis paper aims to show the results from a pioneering primary care‐based extended scope physiotherapist (ESP) led service, which placed patients directly onto the surgical waiting list of secondary care orthopaedic consultants over a two‐year period.Design/methodology/approachA retrospective data review was performed on all referrals from community‐based ESPs for direct listing at the secondary care hospital between 2 January 2008 and 31 December 2009.FindingsA total of 130 referrals for direct listing were made by the ESP team during the two‐year period. Of these, 127 (98 per cent) went on to undergo a THR. Three patients (2 per cent) did not ultimately have a THR.Research limitations/implicationsThis process has continued over the two years of the direct listing service, with ongoing evaluation and refinement of the pathway, so referral criteria and clinical/administrative pathways have been changed in the light of experience.Practical implicationsPatients who were directly listed did not require a hospital orthopaedic outpatient appointment until attendance at preoperative assessment clinic shortly before their surgery. In addition to the reduction in inconvenience and travelling costs incurred by patients, there was an approximate saving of £145 to the primary care trust per directly listed patient.Originality/valueThe authors believe that this service evaluation is the first publication to show that direct listing by primary care based ESPs is a safe and effective process for some patients requiring primary THR.

To work with service users and providers to optimise the design and implementation of handover forms to support the transfer of information between daytime and out-of-hours primary care services for patients with palliative care needs. There is a need for improved informational continuity between daytime and out-of-hours primary care services for patients with palliative care needs. Research suggests that while handover forms are vital to ensure continuity of care, they remain underused for such patients. Audit work in an out-of-hours primary care service in South West England identified that their current system of handover forms was underused. An action research study consisting of two phases was undertaken. In phase one, the views of general practitioners and nurses working in the out-of-hours and daytime primary care services (29 health professionals) in Devon (population c.1.4 million) and patients with palliative care needs and their carers (8 participants) were investigated using qualitative interviews and focus group methods. Participants' views on the content and use of handover forms, and of the systems supporting their generation were sought. In phase two, additional feedback from the health professional stakeholder groups was collected and collaborative work undertaken with the out-of-hours service to implement recommendations emerging from the qualitative research. Findings Respondents identified variable use of handover forms and inconsistent practice in terms of: who was responsible for generating and updating forms; when and where they were discussed in primary care; the criteria used to define which patient needed a form; and the information forms should contain. There was uncertainty about how handover forms were used by the out-of-hours service and concerns about incomplete access to forms for certain groups of staff. An action plan to improve the existing system was developed. This included distribution of educational materials (desktop guide, newsletter) to key stakeholders, and the modification of information systems to facilitate the updating of messages and the accessibility of electronic records for previously under-served staff.

As an emergency care practitioner (ECP) in the south west of England, I must reply to the news item ‘Emergency care practitioners will aggravate “inter-professional tension” ’ (news August 30).

Edited by a general practitioner and a cancer specialist, Cancer in Primary Care aims to provide a single reference point for primary healthcare team members to access basic information necessary for holistic cancer care. Most of the text is directed to specific types of cancer, with each chapter dealing with a specific site and providing concise descriptions of incidence, pathology, diagnosis and staging and management. HIV-associated cancer is dealt with in a separate chapter. The data are up-to-date for a 2003 publication and for the most part presented in colourful and graphic format. The chapter on children's cancer is particularly helpful because the conditions are rare and usually managed in regional centres. The five-year actuarial survival curves provide an encouraging visual representation of the progress made in the treatment of childhood leukaemias and I found the table relating to common presenting signs and symptoms of childhood malignancy, with associated differential diagnoses, a useful aide-memoire. The introductory section of the book deals with organizing a cancer service and does not appear immediately relevant to a busy health professional with a specific question. I liked the chapter on managing side effects of cancer therapy, compressing a lot of data into a short readable essay. The book finishes with a comprehensive listing of information and support sources for cancer patients, which provides general national and disease-specific information with web addresses. A subject now fraught with difficulties for the general practitioner is prostate cancer—especially with regard to the place of prostate specific antigen (PSA) estimation. I took issue with the statement that ‘men who present with prostatism should be assessed initially with digital rectal examination and PSA estimation’. This is not the consensus in the UK and such a policy, if followed blindly, can lead to a series of further investigations not necessarily in the patient's best interest. That point aside, the prostate chapter does offer a balanced discussion of the treatment options of localized and metastatic prostate cancer with recent trial results presented in an accessible manner which clarified some issues for me. Does a book of this sort serve a useful purpose in an age of rapid change in screening technology, imaging and treatment options? Will the text be ‘dipped into’ by the primary healthcare team as the authors hope, or will the internet and nationally agreed statements be the preferred route. The long-term future, I suspect, is for such texts to be available electronically with regular updates.