What helps or hinders the communication of poor prognosis between secondary and primary care? A systematic review with narrative synthesis
BackgroundThe communication of poor prognosis from secondary to primary care helps to ensure that patients with life-limiting illness receive appropriate coordinated care in line with their preferences. However, little is known about this information-sharing process.AimTo determine how poor prognosis is communicated from secondary care to primary care.Design and settingThis was an international systematic review and narrative synthesis of studies published in English.MethodFour electronic databases were searched from 1 January 2000 to 17 May 2021, supplemented by hand-searching of key journals. One-quarter of titles and abstracts were independently screened by a second reviewer. Two reviewers undertook data extraction and quality appraisal, independently using the Mixed Methods Appraisal Tool. Data were analysed using narrative synthesis. Reporting follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.ResultsSearches identified 23 853 unique studies of which 30 met the inclusion criteria. Few studies had a focus on the interprofessional communication of poor prognosis. Information about prognosis was not commonly communicated from secondary to primary care and was more likely to occur if death was imminent. Lack of identification of poor prognosis by secondary care teams was a barrier. Facilitators included shared electronic records and direct clinician–clinician contact. GPs welcomed this information from secondary care and felt it was vital for continuity of care.ConclusionAlthough the communication of poor prognosis from secondary to primary care is highly valued it is rare and associated with cultural and systemic challenges. Further research is necessary to understand the information needs of GPs and to explore the challenges facing secondary care clinicians initiating this communication.
Improving personal continuity in general practice: a focus group study
BackgroundPersonal continuity is an important dimension of continuity of care in general practice and is associated with many benefits including a higher quality of GP care and lower mortality rate. Over time, changes in society and health care have challenged the provision of personal continuity. Older patients in particular experience more negative consequences from receiving discontinuous care.AimTo explore the perspectives of GPs, older patients, practice nurses, and assistants on improving personal continuity in general practice, and to identify barriers and facilitators that affect this improvement process.Design and settingA qualitative study using focus groups was conducted from May to August 2019.MethodWe organised four focus groups: two with GPs (n = 17), one with patients (n = 7), and one with practice assistants (n = 4) and practice nurses (n = 2). Focus groups were analysed using reflexive thematic analysis.ResultsPersonal continuity was viewed as being provided by the entire general practice team and not just by the patient’s own GP. It was suggested that investing in team communication and stability (for example, by efficient use of the electronic health records) and retaining the availability and accessibility of the patient’s own GP for patient care, especially for frail older persons, (for example, by delegating tasks) could improve personal continuity. Barriers and facilitators were perceived at the individual (for example, GPs’ involvement in tasks), organisation (for example, staff shortages), and societal level (for example, payment system).ConclusionAs general practice moves towards a more team-based approach to ensure personal continuity, efforts to improve personal continuity should focus on supporting team-based provision of continuous care.
Creating an international community of practices to support newly qualified GPs
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Forget sun, sand, and surf, who needs Australia when you’ve got general practice?!
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GPs and assisted dying
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‘Flattened, fattened, and forgotten’: the ‘dis-integrated’ care of patients prescribed antipsychotics in the UK
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Structured medication reviews: progress since 2020 and opportunities for improvement
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Standing up for general practice
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The enshittification of general practice
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Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study
BackgroundSince 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services using a hybrid of remote, digital, and in-person care.AimTo examine how quality domains are addressed in contemporary UK general practice.Design and settingMulti-site, mostly qualitative longitudinal case study, placed in UK national policy context.MethodData were collected from longitudinal ethnographic case studies of 12 general practices (2021–2023), multi-stakeholder workshops, stakeholder interviews, patient surveys, official reports, and publicly accessible patient experience data. Data were coded thematically and analysed using multiple theories of quality.ResultsQuality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised.ConclusionContemporary hybrid general practice features changes (digitalisation, physical distancing, extension of roles, and protocolisation) that have had the unintended effect of dehumanising, compromising, and fragmenting care. Policymakers and practices should urgently address the risks to patients and the traditional core values of general practice should be urgently addressed.