281 research outputs found
Beyond the limits of clinical governance? The case of mental health in English primary care
No full textBackground. Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'. Methods. Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision. Results. The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care. Conclusion. Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply. © 2008 Gask et al; licensee BioMed Central Ltd
Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from 'hard to reach' groups
No full textKnowledge about depression, access and help-seeking has increasingly been influenced from a range of disciplines including clinical and applied social science. A range of interventions can improve outcomes of depression and anxiety. However, many in need do not seek help, or their interaction with care-givers does not address their needs. We carried out a systematic search for qualitative articles focusing on the experiences of eight exemplar groups with exceptional problems in access (the homeless, long-term unemployed, adolescents with eating disorders, depressed elderly people, advanced cancer sufferers, patients with medically unexplained symptoms, asylum seekers and people from black and minority ethnic groups). Twenty articles representing these groups were selected, findings were then developed using qualitative meta-synthesis, this suggested a range of mechanisms accounting for poor access among these groups. Many regarded their mental health problems as rooted in social problems and employed a variety of self-management strategies to maintain function. These strategies could involve social withdrawal, focusing available resources on close family relationships and work roles. Over-investment in these roles could result in a sense of insecurity as wider networks were neglected. Material disadvantage affected both the resources people could bring to performing social roles and influenced help-seeking. A tacit understanding of the material, psychological and social 'costs' of engagement by patients and health professionals could influence decisions to seek and offer help. These costs were felt to be proportionally higher in deprived, marginalized and minority communities, where individual resources are limited and the stigma attached to mental ill-health is high. © The Author(s) 2011
Domains of consultation research in primary care
No full textThe consultation is increasingly viewed as a crucial aspect of general practice medicine, but a variety of methods of conceptualising, describing and modifying its structure and content have been described. This article describes the historical background to the current interest in the consultation, and describes four qualitatively distinct approaches (or ‘domains’) to understanding the consultation: the psychodynamic; clinical–observational; social–psychological; and sociological. Four key dimensions along which the domains can be differentiated are described. These concern whether the critique of medical practice inherent in the domain is internal or external to the discipline of general practice; whether the focus of the domain is on the consultation participants’ identities or activities; whether the key research methodology is quantitative or qualitative in character; and the degree to which the objective of research within the domain is to describe current practice or prescribe ways of conducting the consultation. Methods of encouraging work across domains are discusse
Teaching mental health skills to general practitioners and medical officers.
No full textDavid Goldberg opened by describing the research that had led up to the present WPA teaching package. Early research had demonstrated that many psychological illnesses were not detected in primary care settings (Goldberg & Huxley 1980; ibid 1992), and these findings have been replicated in 14 centres round the world, with broadly similar results (Ustun & Sartorius 1995). We have found that in the UK the problem is not defects in factual knowledge, but not having clinical skills to assist in the management of mental disorders in general medical settings. The clinical skills needed in primary care are seldom taught in medical schools, and cannot be learned by listening to a lecture: it is necessary to practice them after they have been demonstrated. To do this it is convenient to break complex clinical skills down into their components: these are called "micro-skills", and we will deal later with the way in which these are taught. The most powerful method for improving mental health skills in this setting is to provide doctors with feedback--either video or audio--of their interview with real patients. The emphasis of such teaching must be on the interview techniques used by the doctor, rather than the clinical problems displayed by the particular patient being interviewed (Gask et al 1991). The problem with this is that video-feedback teaching of the necessary type is not always available, so we have developed videotapes that we can send out to distant locations, and which focus the attention of both local tutor and postgraduates on what should be learned. Because it is essential that most of the teaching is done by the live teacher rather than the videotape, there are always several "discussion points" so that postgraduates can ask questions, or describe their own way of dealing with particular situations. The videotapes are supplied together with teaching notes for the tutor, power points slides which can be adapted to suit local conditions, "role plays" to allow postgraduates to practice each skill they wish to learn, and other support materials. There is also a paper written by ourselves in association with Norman Sartorius, who has encouraged us to prepare the teaching package under the auspices of the WPA. Linda Gask described the process of teaching specific 'microskills', by working through how the skills necessary for the management of people who present in primary and general medical settings have been described and taught in the UK (see box 1). A model of the strategies and skills to be [figure: see text] taught was first developed utilizing the experience professionals and teachers from both primary care and mental health. A videotape was produced in which the skills to be acquired were demonstrated by real primary care doctors in role-played interviews with the addition of subtitles to label particular skills. The videotape is then utilised in a group teaching session to model the specific component skills of the model or 'microskills' to the participants in order to demonstrate exactly how the strategies of the model are applied in a real consultation. Watching the videotape will not however change behaviour. To do this, it is necessary to role-play brief scenarios so that the professional is able to practice the actual words he or she would use. This role-play work may be carried out in pairs, with one doctor playing the professional and the other playing the patient, or in threes, with the addition of an observer who ensures that the participants keep to the task. At the end of the role-play all participants provide feedback. These methods are described in much more detail in Gask (1999). Finally, there is also the possibility of videotaping one of these role-played interviews and teaching on this tape with the group as a whole. The specific skills and methods required to do this are described in much more detail along with the research evidence for these methods in Gask (1998). Our approach to facilitating the group in the exercise of videofeedback teaching is summarised in box 2
Understanding the implementation of complex interventions in health care: the normalization process model
No full textBackground: the Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice. It offers a framework for process evaluation and also for comparative studies of complex interventions. It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice.Methods: a formal theory structure is used to define the model, and its internal causal relations and mechanisms. The model is broken down to show that it is consistent and adequate in generating accurate description, systematic explanation, and the production of rational knowledge claims about the workability and integration of complex interventions.Results: the model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions (interactional workability, relational integration, skill-set workability, and contextual integration).Conclusion: the model is consistent and adequate. Repeated calls for theoretically sound process evaluations in randomized controlled trials of complex interventions, and policy-makers who call for a proper understanding of implementation processes, emphasize the value of conceptual tools like the Normalization Process Mode
Teaching mental health skills to general practitioners and medical officers.
No full textDavid Goldberg opened by describing the research that had led up to the present WPA teaching package. Early research had demonstrated that many psychological illnesses were not detected in primary care settings (Goldberg & Huxley 1980; ibid 1992), and these findings have been replicated in 14 centres round the world, with broadly similar results (Ustun & Sartorius 1995). We have found that in the UK the problem is not defects in factual knowledge, but not having clinical skills to assist in the management of mental disorders in general medical settings. The clinical skills needed in primary care are seldom taught in medical schools, and cannot be learned by listening to a lecture: it is necessary to practice them after they have been demonstrated. To do this it is convenient to break complex clinical skills down into their components: these are called "micro-skills", and we will deal later with the way in which these are taught. The most powerful method for improving mental health skills in this setting is to provide doctors with feedback--either video or audio--of their interview with real patients. The emphasis of such teaching must be on the interview techniques used by the doctor, rather than the clinical problems displayed by the particular patient being interviewed (Gask et al 1991). The problem with this is that video-feedback teaching of the necessary type is not always available, so we have developed videotapes that we can send out to distant locations, and which focus the attention of both local tutor and postgraduates on what should be learned. Because it is essential that most of the teaching is done by the live teacher rather than the videotape, there are always several "discussion points" so that postgraduates can ask questions, or describe their own way of dealing with particular situations. The videotapes are supplied together with teaching notes for the tutor, power points slides which can be adapted to suit local conditions, "role plays" to allow postgraduates to practice each skill they wish to learn, and other support materials. There is also a paper written by ourselves in association with Norman Sartorius, who has encouraged us to prepare the teaching package under the auspices of the WPA. Linda Gask described the process of teaching specific 'microskills', by working through how the skills necessary for the management of people who present in primary and general medical settings have been described and taught in the UK (see box 1). A model of the strategies and skills to be [figure: see text] taught was first developed utilizing the experience professionals and teachers from both primary care and mental health. A videotape was produced in which the skills to be acquired were demonstrated by real primary care doctors in role-played interviews with the addition of subtitles to label particular skills. The videotape is then utilised in a group teaching session to model the specific component skills of the model or 'microskills' to the participants in order to demonstrate exactly how the strategies of the model are applied in a real consultation. Watching the videotape will not however change behaviour. To do this, it is necessary to role-play brief scenarios so that the professional is able to practice the actual words he or she would use. This role-play work may be carried out in pairs, with one doctor playing the professional and the other playing the patient, or in threes, with the addition of an observer who ensures that the participants keep to the task. At the end of the role-play all participants provide feedback. These methods are described in much more detail in Gask (1999). Finally, there is also the possibility of videotaping one of these role-played interviews and teaching on this tape with the group as a whole. The specific skills and methods required to do this are described in much more detail along with the research evidence for these methods in Gask (1998). Our approach to facilitating the group in the exercise of videofeedback teaching is summarised in box 2
Health technology assessment in its local contexts: studies of telehealthcare
No full textHealth technology assessment (HTA) is one of the major research enterprises of late modernity, reaching into fields of previously autonomous professional practice, and critically interrogating the organisation and delivery of health care. The ‘evaluation’ of new health technologies within the field of HTA is increasingly a normative political expectation, as discourses of ‘evidence-based’ practice run through health policy in the UK and elsewhere. Despite its importance in governing the direction of innovation in health care delivery, there are hardly any empirical studies of HTA in practice. In this paper, we draw on two ethnographic studies of telehealthcare implementation and evaluation in the UK to explore the practical conduct of HTA, and we focus specifically on the social organisation and conduct of randomised controlled trials of these new technologies. The paper examines how evaluation forms a mediating set of practices that make the embedding or normalisation of a new technology possible; and present a simple model of the social and technical contingencies within the evaluation proces
Integrating service development with evaluation in telehealthcare: an ethnographic study
No full textObjectives: to identify issues that facilitate the successful integration of evaluation and development of telehealthcare services.Design: ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings.Setting: seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties—dermatology, psychiatry, respiratory medicine, cardiology, and oncology.Participants: clinicians, managers, technical experts, and researchers involved in the projects.Results and discussion: key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study.Conclusions: combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NH
Normative models of health technology assessment and the social production of evidence about telehealth care
No full textTelehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of ‘evidence’ is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problem
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