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The role of nurses in general practice: General Practitioners' and Practice Nurses' perceptions is a study that identifies the beliefs of Practice Nurses (PNs) and General Practitioners (GPs) of the PN role and how those roles impact on the general practice. Ethnographic techniquess were used for this study, with data collected through interviews, observation and questionnaires. Interviews were conducted with four PNs and four GPs in practices that employed nurses in an increased role similar to that described in the Nursing in General Practice Fact Sheets (Royal College of Nursing Australia, 2002). Two practices were observed to identify work practices and the nurses' interaction within the practice. The main finding of the study was the importance placed on the general practice team. Both GPs and PNs believed that working as a team was vital. They indicated that working together provided holistic care and enabled the practice to provide quality care. The role of the PN in this study was consistent with other studies in Australia. However, the nurses in this study appeared to have more autonomy in regard to care of people with chronic illness and the aged. Continuing education was considered important for the further development of the PN role. However, participants believed that the PN also needed to have considerable and varied experience together with good people skills. To further develop the PN role innovative ways of providing education to PNs should be investigated to ensure nurses have the necessary skills to undertake their role. Payment issues in general practice should also be examined and addressed to ensure that PNs are able to be employed, and receive remuneration appropriate for their experience and job description.

There is demand for homeopathy in England amongst both doctors and patients. Exploring this demand remains the key to understanding the extent of integration of homeopathy in Primary and Secondary Care Practice and the potential significance of the role of GPs as gatekeepers. This thesis explores how qualified General Practitioners (GPs) and Medical Homeopathic Physicians in England adopt homeopathy as a healthcare innovation, and employ and integrate homeopathy treatments in their everyday work within healthcare practice in England. This study was conducted prior to the large scale changes that were introduced by NHS Mobilisation June 2010, championing the spread of activity to support the cost and quality agenda across the NHS, captured in the Quality, Innovation, Productivity and Prevention (QIPP) goals, during the period covered by this study. The term, “integrative medicine” has become a common term to describe teams of health care providers working together to provide patient care. It is currently used interchangeably with complementary and alternative medicine, and at other times refers to treatments that combine conventional medicine and alternative modalities. The aim of this thesis is to determine how homeopathy is integrated into healthcare, its clinical and practice benefits and how GP/Medical Homeopath Physicians’ views and experiences effect integration. This two phase study, using an adapted General Practice Assessment Questionnaire (GPAQ), to audit patient satisfaction, explored patient experiences of available homeopathic services in two established Primary Care GP Practices between 2007 and 2008 and further explored in 2009 twenty General Practitioners and Medical Homeopathic Physicians views of the integration of homeopathy, through semi structured telephone interviews. The findings in Phase One confirm that homeopathy has been integrated to a degree within the National Health System (NHS) in England since its inception in 1948. Two Geographical Information Systems Maps utilised in this study identified and illustrated the locality of GP homeopaths in England and explored geographical demographics associated with homeopathy availability and use. A clinical audit of two established homeopathy services report patients satisfaction with the homeopathic services provided in Primary Care settings. Phase Two findings identified that Non-Homeopath GPs were not antagonistic about the use of homeopathy in Primary Care practice. Constraints against full integration of homeopathy were not specifically related to gate keeping but those predominately of the time necessary to fit in homeopathic consultations within regular patient consultation time. This is coupled with findings from the Medical Homeopathic Physicians that indicate it is not the future of homeopathy that is in question but that of the NHS itself.

Increasing collaborative working between GPs and community pharmacists has recently become a high priority for the NHS. Previous research suggests that interaction is limited and problematic between the two professions, forming a barrier to service provision. This PhD aimed to explore the level, nature and process of interaction between GPs and community pharmacists, using a social network analysis approach.The study focused on four geographically different case study areas and 90 GPs and community pharmacists participated in total. A two-stage design was adopted. Firstly data were collected through a network questionnaire and analysed using social network analysis. Secondly, qualitative interviews were conducted to provide narrative to the network findings and analysed using the framework approach.The nature of contact was characterised as mostly indirect through brokers, de-personalised and non-reciprocal and seemingly at odds with collaborative behaviour. A misalignment in responses pointed to asymmetry in the relationship, representing little commonality, knowing and understanding of each other. Through social network analysis, individuals and dyads in possession of strong ties were identified. Strong ties were not the norm and were characterised by more personalised forms of reciprocal contact. Qualitative interviews provided insight into the processes of interaction between the two professional groups. An approach to the interaction, which involved pharmacists tactically managing the potential conflict in the interaction through use of deferential and sometimes subservient behaviour, was conceptualised as the ‘pharmacist-GP game’. Those pharmacists with strong ties to GPs also, at times, adopted aspects of this approach but also attempted to set themselves apart from other pharmacists in order to develop and maintain their strong ties with GPs. However, possession of strong ties did not always lead to capitalisation, and the benefits of possessing these were often viewed as efficiency and convenience gains rather than anything more wide-reaching. Often, more isolated GPs and pharmacists did not view strong ties as a necessity, with the benefits of these not considered rewarding enough for the time and effort required to achieve them. This effort-reward conflict was identified as an important constraint faced by GPs and pharmacists in relation to transforming these loose connections into more integrated networks. Other micro and macro level constraints were also identified and a series of accompanying recommendations made for future practice and research.

<p>There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. </p><p>Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery <i>and</i> proper management of sick-listing (II). </p><p>Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV).</p><p>Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.</p>

The overall aim of the thesis is to explore the determinants of General Practitioner (GP) referrals to specialist mental health services, in particular psychological therapy. Paper 1 is intended to contribute to this literature by providing a systematic review of GP and organisational factors identified as impacting on referral in previous research. According to this literature, referral to a mental health specialist was more likely if the GP does not feel that they have the 'capacity to help' and perceives 'time constraints' on how long they can spend with the patient. Referral also appeared more likely if the GP felt they had acceptable 'access to services' and if they had a close 'consultation/liaison' relationship with specialists. The theoretical and clinical implications of these findings are discussed, and gaps in the current literature identified for further research. Paper 2 describes an empirical study aimed at exploring the determinants of GP referral for psychological interventions within Primary Care Mental Health Services (PCMHS). 132 GPs completed questionnaires, including demographic information, attitudes towards mental health and its treatment and responses to short fictional case vignettes indicating their likelihood of referral to the PCMHS. Qualitative results suggested that GPs consider a range of factors in their referral decisions, including patient preference, severity of the problem, access to services and the effectiveness of the service. Alternative options considered included signposting to other services, reviewing, medication and providing advice and support. Quantitative results suggested that younger GPs reported a higher likelihood of referral, and were more likely to refer in line with guidelines. Psychological factors were not associated with referral likelihood or referral in agreement with guidelines. In line with previous research on clinician behaviour, findings of papers 1 and 2 are considered primarily in the context of the Theory of Planned Behaviour, and the utility of this model in predicting referral behaviour is evaluated throughout. A greater understanding of predictors of referral is thought to be valuable in designing clinician and service level interventions to improve the proportion of those in need who are able to access psychological therapy. Paper 3 provides a critical evaluation of the research process as a whole, including the processes involved in the literature review and empirical study. The strengths and weaknesses of both of these elements are discussed, along with an evaluation of the overall approach taken throughout the thesis. The findings of both studies are integrated and discussed in the context of current policy and proposed changes to healthcare provision. Implications for theory, clinical practice and further research are discussed.

<p>The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients.</p><p>Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged.</p><p>The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.</p>

The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients. Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged. The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.

There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery and proper management of sick-listing (II). Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV). Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.

This thesis applies the econometric projection approach to forecast the numbers of general practitioners (GPs) in Saskatchewan for the next 15 years at both provincial and the Regional Health Authorities (RHAs) levels. The projection results will provide the estimated level of GPs up to 2021 for policy makers to adjust their decision on health professionals planning.<p> Three hypothesized scenarios, which include the changes in population proportion, average income for GPs and a combination of both, are used for projections based on the regression results. The projections suggest a 4.34% expected annual increase of GPs if the proportions of children and seniors increase or decrease according to prediction for the next 15 years for Saskatchewan. At the RHAs level, 4.5% to 10.7% expected annual rate of increase for numbers of GPs is projected for the northern RHAs and Saskatoon RHA, while the expected increase for other urban RHAs will experience less than 1.5% increases.<p> The predicted changes in average income for GPs show insignificant effect for the expected changes in numbers of GPs. However, the second and third scenarios are not extended to the RHAs level due to lack of information, which requires additional data for both Saskatchewan physicians and population for further projection analysis.