Literature Collection

BACKGROUND: Since the Declaration of Alma-Ata in 1978 (1) global health policy has prioritised primary and integrated care reform to better manage chronic illness, improve health access, and prevent disease.(2) Yet internationally primary care, like the health systems it struggles to support, is currently far from strengthened; and is increasingly challenged by chronic underfunding, lack of recognition, and a diminishing and demoralised workforce.(3,4) AIM: To better understand the policy barriers responsible for the current status from the perspective of general practice in England DESIGN & SETTING: Key Informant Interviews with 12 general practice policy or practice leaders identified from publicly-available position statements, publications or innovative programs in UK primary care reform over the past decade METHOD: A qualitative deductive approach using thematic analysis to analyse informant data to understand historical barriers and explore enablers for future reform. RESULTS: The analysis resulted in eight main themes. 1. Dynamics of power and autonomy 2. Under-investment in primary care 3. Aligning policy and implementation 4. Navigating complexity and change 5. Building trust through relationships and leadership 6. The revolving door of policy and leadership 7. Valuing the workforce: A key to morale and retention 8. Strategic communication and media engagement CONCLUSION: Better-targeted funding reform, more effective systems integration building on general practice and community service strengths, and better valuing the complex role of the primary care sector as central to a high-functioning health system, were seen as key to the future. Participants also called for more effective policy input from those skilled in the delivery of care, and the capacity for earned autonomy and flexibility to deliver care relevant to individual community need. Action to address these opportunities is pressing, as finalisation of the 10 Year Health Plan and more-immediate NHS restructure rapidly gathers momentum.

BACKGROUND: High blood pressure (BP) is a leading cause of morbidity and mortality. Blood pressure home monitoring improves blood pressure control, but there is limited evidence about the implementation of specifically 'technology-enabled' remote monitoring of blood pressure (TERM BP) at home. This evaluation aims to improve the evidence base on what constitutes TERM BP services, how they work, and what influences their implementation, impacts, spread, and scale. METHODS: A multi-method, rapid qualitative evaluation involved four sites that implemented TERM BP. Across sites, we conducted interviews with staff (n = 35) and patients (n = 15) and analyzed key service documents. Three workshops with site staff, patients, and regional and national stakeholders helped refine the learning process. Thematic analysis and synthesis, and triangulation against existing literature, helped inform recommendations and was guided by the Non-adoption, Abandonment, and challenges to Scale-up, Spread and Sustainability of the technology framework. Patient and public voices informed the evaluation design and conduct. RESULTS: TERM BP implementation varies in governance, patient eligibility, technology, workforce, and workflow. Perceived impacts include improved blood pressure control, case-finding, and a more efficient workload distribution. The parallel running of technology-enabled and paper-based pathways mitigates access inequalities, but involves a high administrative workload. Sociotechnical influences on implementation relate to technology user-friendliness and adaptability, health system relationships and resources, practice capabilities and learning cultures, and patient acceptability and enablement. Flexibility within a planned, gradual approach that embeds skills in teams and systems and impacts evidence generation support scale and spread. CONCLUSIONS: Technology and social forces co-evolve to shape TERM BP pathways and manage co-existing tensions, including planning, emergence, demand, and capacity. Decision makers should establish implementation guidance and commissioning criteria, address regulatory issues, and enable evidence generation and shared learning. Further research is needed on the impact of TERM BP, especially in integrated care and related to inequalities.; High blood pressure affects more than a quarter of the population in the UK. Managing it well can help prevent further health problems. One way to help people control high blood pressure is to use devices such as home blood pressure monitors and mobile phones. This is called technology-enabled remote monitoring of blood pressure at home. We still need to understand more about what works well when using technology-enabled remote monitoring. In this study, we looked at how, where, why, and for whom technology-enabled remote monitoring of blood pressure is used. We interviewed 35 healthcare professionals and 15 patients across four sites (for example, general practices). We held three workshops with healthcare professionals, other decision makers, and patients to discuss and refine the findings. We found that technology-enabled remote monitoring of blood pressure was used in various ways. Sometimes, the service is delivered by general practice and sometimes by staff working in a local area to support patients across many general practices. At most sites, technology-enabled remote monitoring is managed by a nurse or pharmacist instead of a general practitioner (GP). Support from a variety of clinical and non-clinical staff is important. Most patients were engaged and motivated to use technology-enabled remote monitoring, although some were concerned about whether they were using the monitors correctly. The patients also highlighted that technology-enabled remote monitoring may not be a good fit for everyone. Technology-enabled remote monitoring can support both patients and healthcare professionals in managing high blood pressure, but more research is needed to understand the wider impact (e.g., on demand for GP appointments). Decisionmakers should consider how technology-enabled remote monitoring can be gradually expanded to reach more people. Planning is needed to ensure that it is widely accessible and does not place too much extra burden on the staff.; eng

BACKGROUND: Sleepio, a digital therapeutic offering digital cognitive behavioral therapy for insomnia, has been recommended by the National Institute for Health and Care Excellence in the United Kingdom as an alternative to offering sleep hygiene or sleeping pills. However, understanding of the referral behavior of general practitioners (GPs) regarding Sleepio is lacking. OBJECTIVE: The aim of this study was to investigate the feasibility of using an intervention targeting GPs in Scotland to increase referrals of patients with insomnia to Sleepio. METHODS: GPs working in primary care in Scotland were invited to join the study. GPs were recruited through the Primary Care Research Network in Scotland from June 10, 2024, to October 13, 2024. The behavior change wheel (BCW) was used to inform the design of the intervention. During the intervention, GPs reviewed an orientation on using Sleepio and received a visual reminder midway through the intervention. The primary outcome was the number of Sleepio referrals every 2 weeks over 2 months. The secondary outcome was the change in the GPs' reported confidence level that Sleepio will be successful in reducing patients' insomnia symptoms, and confidence in recommending Sleepio to patients. RESULTS: Of the 23 GPs who joined the study, 16 completed all stages. Overall, 68.8% (11/16) of participants were females, and the mean age was 42 (SD 8) years. The total number of Sleepio referrals in 2 months was 96 for all 16 GPs. In the first 2 weeks of the intervention, the mean referral rate to Sleepio was 22.4% for all 16 GPs, but this rate increased to 45% by the end of week 8. A repeated measures analysis indicated there was no statistically significant difference in GPs' referral rates across 4 data points. GPs' reported confidence level in recommending Sleepio increased significantly (z=-3.436; P<.001), from a mean of 5.44 (SD 1.7; somewhat confident) to 8.13 (SD 2; very confident). CONCLUSIONS: This study explored the feasibility and impact of an intervention aimed at supporting GPs to refer patients with insomnia to the digital therapeutic, Sleepio. Improvements were seen in GP-reported confidence levels at recommending Sleepio. A large-scale intervention and a longer study duration could provide useful information concerning how long the intervention effect on GPs' behavior toward Sleepio referrals might be maintained.

PURPOSE: This study examined the levels of end-of-life care preparedness, importance, performance, and educational needs among community-based home care workers and identified factors influencing end-of-life care performance to inform hospice/end-of-life care education programs. METHODS: This study used a descriptive, correlational design. The participants were 152 community-based home care workers with at least 6 months of work experience. Data were collected using structured questionnaires that assessed end-of-life care preparedness, importance, performance, and educational needs. Data were analyzed using descriptive statistics, correlation analysis, importance-performance analysis (IPA), and hierarchical multiple regression analysis using SPSS version 29.0. RESULTS: Overall, end-of-life care performance was significantly lower than its perceived importance (t=14.41, P< 0.001), with the largest gaps observed in the caregiving support and emotional support domains. In the IPA, multiple items related to death preparation for patients/families, spiritual/emotional support, and care around the time of death fell into the low-importance/low-performance quadrant. Educational needs positively correlated with importance, intention, confidence, preparedness, and performance. In hierarchical regression, preparedness (β=0.21, P=0.03) and importance (β=0.26, P<0.001) significantly predicted performance, explaining 15% of variance. CONCLUSION: End-of-life care performance among home care workers was influenced by psychological factors, including preparedness, importance, and confidence in end-of-life care, as well as institutional and environmental factors. Standardized educational programs and organizational support are required to improve the quality of community-based end-of-life care.