Progress in partnerships.
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Community Networks↗
Biomedical subjects
C Shipman
Publications and source records attributed to C Shipman.
Cancer services. Left to chance.
Most primary care groups/trusts have cancer lead posts and have some involvement in planning and commissioning cancer services. Cancer is not a high priority in comparison to other national service frameworks and the transition to PCT status. PCG/Ts want help and information about developing cancer services but not all want this now. Most PCG/Ts have some involvement in cancer networks but information needs exist about their role and potential.
Hospitals, Public↗
Clinical disorders of bone resorption.
Clinical disorders in which bone resorption is increased are very common and include Paget's disease of bone, osteoporosis, and the bone changes secondary to cancer, such as occur in myeloma and metastases from breast cancer. Clinical disorders of reduced bone resorption are less common and often have a genetic basis, e.g. in osteopetrosis, and in pycnodysostosis due to cathepsin K deficiency. Bone is metabolically active throughout life. After skeletal growth is complete, remodelling of both cortical and trabecular bone continues and results in an annual turnover of about 10% of the adult skeleton. The commonest disorder of bone resorption is osteoporosis, which affects one in three women over 50 years. Its pathophysiological basis includes genetic predisposition and subtle alterations in systemic and local hormones, coupled with environmental influences. Treatment depends mainly on drugs that inhibit bone resorption, either directly or indirectly. This includes bisphosphonates, oestrogens, synthetic oestrogen-related compounds (SERMs--selective oestrogen receptor modulators) and calcitonin. The most widely used drugs for all disorders of increased bone resorption, including osteoporosis, are the bisphosphonates. Recent elucidation of their mode of action, together with the rapidly increasing knowledge of regulatory mechanisms in bone biology, offers many opportunities for the development of new therapeutic agents.
Animals↗
Patient-perceived benefits of and barriers to using out-of-hours primary care centres.
BACKGROUND: The rapid growth of GP co-operatives has encouraged the development of primary care centres, but little is known about patients' views and experiences of these new forms of out-of-hours service delivery. OBJECTIVES: This study was designed to understand patients' views, expectations and experiences of attending an out-of-hours primary care centre which was part of an inner London GP co-operative. METHODS: Systematic samples of patients using the out-of-hours service received semi-structured interviews covering the decision to contact the service, expectations and experience of the service and, if relevant, the experience of travelling to the primary care centre. Interviews were conducted by telephone between 7 and 10 days after patient contact. RESULTS: Interviews were completed with 55.4% (72/130) of sampled patients who were primary care centre attenders, 50.0% (47/94) of those receiving telephone advice and 45.3% (53/117) of those receiving a home visit. Most attenders of the primary care centre said that they were satisfied with the consultation (90.0%, 65) and were able to get all the help they needed (83%, 60). The speed of being seen and the opportunity of having a face-to-face consultation were key benefits identified. For some, this outweighed difficulties experienced in attending the centre, including arranging transport, caring for other children, managing several children on the journey and travelling while ill. The main barriers patients identified for not wanting to attend the primary care centre included feeling too ill to travel, having other dependants to care for or lacking transportation. CONCLUSIONS: While primary care centres offer patients speedy access to face-to-face consultations, there are a range of obstacles which are encountered. Those who are socially disadvantaged appear likely to experience greatest difficulty, raising concerns about equity in access to services. Out-of-hours services may need to give consideration to patient transport and a more flexible approach to visiting at home if such inequities are to be avoided.
Chi-Square Distribution↗
Patients' experiences of receiving telephone advice from a GP co-operative.
BACKGROUND: The use of the telephone to deliver health care advice has increased considerably in recent years. Little research has been carried out to explore the experience of patients who receive such advice and its acceptability. OBJECTIVES: The aim of this study is to describe the expectations of patients, or third party callers, who had contacted a GP out-of-hours co-operative and their satisfaction with telephone advice received. METHODS: Semi-structured interviews were conducted by telephone 7-10 days after contact with one inner city GP co-operative. RESULTS: A total of 47 telephone consultations were followed up with an interview. Of these, 23 (48.9%) callers had expected to be offered a home visit when they called. Reasons for wanting a home visit were either to do with the nature of the condition and its perceived severity, problems in being able to attend the primary care centre and the risks of travel, or because of problems in communicating over the telephone. Satisfaction with telephone consultations centred mostly on the doctor being able to provide reassurance and give adequate time to allay concerns. The most common reasons given for dissatisfaction were the caller feeling that the doctor could not make a correct diagnosis without having seen the patient, or the caller being made to feel that they were wasting the doctor's time. Many patients were anxious about their ability to describe symptoms over the telephone, or understand and follow the advice that they received. CONCLUSIONS: There appears to be a need for patients to be better informed about the service they can expect to receive from GP co-operatives. Recent developments such as NHS Direct may have an influence on the telephone consultation rate to GP co-operatives.
Adolescent↗
Educational opportunities in palliative care: what do general practitioners want?
It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.
Adult↗
Patient satisfaction with out-of-hours services; how do GP co-operatives compare with deputizing and practice-based arrangements?
BACKGROUND: Although the rapid growth in general practitioner (GP) co-operatives has met with GP satisfaction, little is known about patient satisfaction. This study compares patient satisfaction with co-operative, GP practice-based and deputizing arrangements within one geographical area 15 months after a co-operative had become established; and with telephone, primary care centre and home consultations within the co-operative. METHODS: A validated postal questionnaire survey of weighted samples of patients making contact with the co-operative, practice-based and deputizing arrangements was undertaken. RESULTS: A total of 1,823 (53.2 per cent) patients responded. There were no significant differences between organizations in terms of overall satisfaction, but patients using practice-based arrangements were significantly more satisfied with the waiting time for telephone consultations (p<0.001) and more satisfied with waiting times for home visits than deputizing patients (p=0.020). Within the co-operative, overall satisfaction, satisfaction with the doctor's manner and with the process of making contact was greater among those attending the primary care centre, and satisfaction with explanation and advice received greater than for patients receiving telephone consultations alone (p<0.01). Those receiving telephone advice reported increased information needs and help seeking during the following week (p< 0.05). CONCLUSIONS: Overall, patients were as satisfied with the co-operative as with practice-based or deputizing service arrangements, although many concerns were expressed about the quality of service provision. Differences in satisfaction were greater between forms of service delivery within the co-operative. Dissatisfaction with telephone consultations needs to be considered, together with issues relating to equity in access to out-of-hours' primary care centre consultations and the potential impact of NHS Direct.
Aged↗
Providing palliative care in primary care: how satisfied are GPs and district nurses with current out-of-hours arrangements?
The complex needs of palliative care patients require an informed, expert, and swift response from out-of-hours general medical services, particularly if hospital admission is to be avoided. Few general practitioners (GPs) reported routinely handing over information on their palliative care patients, particularly to GP co-operatives. District nurses and inner-city GPs were least satisfied with aspects of out-of-hours care. Most responders wanted 24-hour availability of specialist palliative care. This indicates a need to develop and evaluate out-of-hours palliative care procedures and protocols, particularly for GP co-operatives, and to improve inter-agency collaboration.
Adult↗
The pharmacology of bisphosphonates and new insights into their mechanisms of action.
Bisphosphonates are chemically stable analogs of inorganic pyrophosphate, which are resistant to breakdown by enzymatic hydrolysis. The biological effects of bisphosphonates on calcium metabolism were originally ascribed to their physico-chemical effects on hydroxyapatite crystals. Although such effects may contribute to their overall action, their effects on cells are probably of greater importance, particularly for the more potent compounds. Remarkable progress has been made in increasing the potency of bisphosphonates as inhibitors of bone resorption, and the most potent compounds in current use are characterized by the presence of a nitrogen atom at critical positions in the side chain which, together with the bisphosphonate moiety itself, seems to be essential for maximal activity. As a class the bisphosphonates offer a very effective means of treating Paget's disease.
Animals↗
Responding to out-of-hours demand: the extent and nature of urgent need.
BACKGROUND: Little research has been undertaken concerning GPs' perceptions about urgent or 'appropriate' out-of-hours demand. OBJECTIVE: We aimed to measure GPs' perceptions about patients' need for urgent out-of-hours general medical help according to indicators of physical, psychological/emotional and social need, and the medical necessity of a home visit. METHODS: Twenty-five practices participated in an audit and research study whereby GPs completed an audit form for all contacts during November/December 1995 and February/March 1996. Each contact was assessed according to the indicators of urgent need and GPs commented on reasons for making such assessments. RESULTS: Audit forms were completed on 1862 patients, and GPs considered that 66.6% (1027) of contacts had either a physically, psychologically/emotionally or socially urgent need for help and were uncertain about a further 10.7% (165). Over half (53.0%) were considered to have an urgent physical need, almost one-third (31.0%) to have an urgent psychological/emotional need and 10.1% (119) to have an urgent social need for help. Over half (55.2%) of visits were considered to be medically necessary, the majority of which (89.9%) were assessed as having an urgent physical need for help. CONCLUSIONS: The findings raise questions about the strategic direction of newer forms of service delivery (GP Co-operatives) and suggest the need for further research to inform the strategic reduction in home visiting, particularly in inner-city areas where many residents have little access to transport out-of-hours to enable them to attend a primary care centre. GP co-operatives are, however, well placed to improve interagency working and cross-referral to other health and social service personnel, and respond more 'appropriately' to some psychological/emotional and social problems.
Adolescent↗
Access to and use of out-of-hours services by members of Vietnamese community groups in South London: a focus group study.
BACKGROUND: Communication difficulties, lack of knowledge of services and the appropriateness of services influence access to health care services by black and ethnic minority groups. These problems may be accentuated outside normal working hours. This may be so particularly for those who do not speak English as a first language, as interpreting services across the UK are extremely limited in the out-of-hours period. OBJECTIVE: We aimed to describe the experiences and perceptions of members of the Vietnamese community groups in seeking out-of-hours health services and to identify potential solutions from participants' perspectives. METHOD: This qualitative study used a focus group methodology. Participants were members of three established community groups in the South London boroughs of Southwark and Lewisham. Participants attended six focus groups which were conducted in Cantonese and Vietnamese. RESULTS: Participants did not know about GPs' out-of-hours arrangements. And their access to the range of services normally available was limited. They were unable to communicate with health care professionals or answering services and were unaware of out-of-hours interpreting arrangements. Generally, participants were dependent on other people in gaining access to services. Some participants had used 999 services despite communication problems. Participants' experienced delays in seeking health care services and confusion regarding the medicines and advice given. CONCLUSIONS: Communication difficulties limited knowledge of and access to out-of-hours services for the Vietnamese participants. Direct contact with interpreters in the out-of-hours period was suggested as a means of increasing participants' ability to gain access to services. Health service planners need to be aware of the difficulties experienced by such groups if issues of equity in gaining access to health care services are to be addressed.
Adult↗
Specialist palliative care and general practice.
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Family Practice↗
Phosphorylation of triciribine is necessary for activity against HIV type 1.
Triciribine (TCN) is a tricyclic nucleoside with known antineoplastic and antiviral activity. It is a potent and selective inhibitor of HIV-1 and HIV-2, including strains known to be resistant to AZT or TIBO. TCN is phosphorylated to its 5'-monophosphate (TCN-P) by intracellular adenosine kinase (AK), but is not converted to di- or triphosphates. We now report that 5'-phosphorylation is requisite for the activity of TCN against HIV-1. CEM cells incubated with TCN at concentrations ranging from 0.1 to 330 microM gave intracellular TCN-P concentrations from 27 to 775 microM, respectively. There was no difference in the amount of intracellular TCN-P detected in uninfected compared with HIV-1-infected CEM cells. The antiviral effect of TCN against HIV-1 was strongly antagonized by the AK inhibitor 5-iodotubercidin (ITu). In contrast, TCN and ITu only exhibited additive cytotoxicity. The 5'-deoxy analog of TCN, which cannot be phosphorylated, had no antiviral effect against HIV-1 at a concentration more than 100 times higher than the IC50 of TCN. Similarly, TCN was not active against HIV-1 in an AK-deficient cell line (AA-2) at concentrations shown to inhibit the virus by >95% in CEM cells. Consistent with its AK-deficient phenotype, this cell line phosphorylated TCN to only 3% of the extent observed in CEM cells. We conclude that TCN must be phosphorylated to TCN-P for activity against HIV-1.
Acenaphthenes↗
Working out of hours: the experiences and training needs of general practitioner registrars.
Out-of-hours work has been identified as a major concern for registrars, and as contributing to the steady decline both in the number of applicants to vocational training schemes and in those practising as principals on completion of their training. Until now, little has been known about registrars' views about their experience of working out of hours and how this might be improved. The present study describes general practitioner (GP) registrars' current patterns of out-of-hours working and their perceptions about training needs.
Attitude of Health Personnel↗
Changing the pattern out of hours: a survey of general practice cooperatives.
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Appointments and Schedules↗
Changes in patient screening for a clinical study of dental implants after increased awareness of tobacco use as a risk factor.
Independent external monitoring committees are an important part of scientific clinical trials. They monitor patient safety, study progress, investigators' performance, and accurate interpretation/reporting of the study data. Data trends observed by a study monitoring committee detected a change in the pattern of patient screening by investigators after an increased awareness that tobacco use could directly compromise the osseointegration of root-form dental implants. This increased awareness is believed to have altered the number of active smokers accepted into a multicenter prospective dental implant study. Recent data analyses indicate that the success ratios were improved by alterations in this discretionary inclusion-exclusion criterion.
Data Interpretation, Statistical↗
Using out-of-hours services: general practice or A&E?
BACKGROUND: General medical and accident and emergency (A&E) services are the two major providers of open access out-of-hours care, and there are widespread concerns about rising and non-urgent demand presented to both. METHODS: This paper examines the differential use of these services out of hours, in an audit and research study two A&E departments and 21 practices in South London. It focuses on aspects of demand, including time of contact, age-related usage and nature of presenting complaints. Through interviews with a subsample of 82 patients who attended A&E, it also provides a more qualitative focus on differential decision making. RESULTS: Findings show that there are differences in the way A&E and general medical services are used in terms of age-related demand and aspects of presenting complaints. Significantly more families with children aged under 10 contacted a GP, and whilst more digestive, respiratory and viral/non-specific complaints were presented to GPs, musculoskeletal problems constituted the largest category of complaints presented at the A&E departments. However, some usage relating to perceived and actual availability of services appeared to be interchangeable in terms of site-of-help seeking. CONCLUSION: There is a need for a collaborative multi-method approach to respond to and influence demand.
Age Factors↗
GPs' views about out-of-hours working.
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Attitude of Health Personnel↗