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Background The prevalence of Human Immunodeficiency Virus (HIV) among prisoners remains high in many countries, especially in Africa, despite a global decrease in HIV incidence. Programs to reach incarcerated populations with HIV services have been implemented in Malawi, but the success of these initiatives is uncertain. We explored which challenges prisoners face in receiving essential HIV services and whether HIV risk behavior is prevalent in prisons. Methods We conducted a mixed-methods (qualitative and quantitative), cross-sectional study in 2018 in six prisons in Southern Malawi, two large central prisons with on-site, non-governmental organization (NGO) supported clinics and 4 smaller rural prisons. Four hundred twelve prisoners were randomly selected and completed a structured questionnaire. We conducted in-depth interviews with 39 prisoners living with HIV, which we recorded, transcribed and translated. We used descriptive statistics and logistic regression to analyze quantitative data and content analysis for qualitative data. Results The majority of prisoners (93.2%) were male, 61.4% were married and 63.1% were incarcerated for 1–5 years. Comprehensive services were reported to be available in the two large, urban prisons. Female prisoners reported having less access to general medical services than males. HIV risk behavior was reported infrequently and was associated with incarceration in urban prisons (adjusted odds ratio [aOR] 18.43; 95% confidence interval [95%-CI] 7.59–44.74; p = p = Conclusions Malawian prisoners reported adequate knowledge about HIV services albeit with gaps in specific areas. Prisoners from smaller, rural prisons had suboptimal access to comprehensive HIV services and female prisoners reported having less access to health care than males. Prisoners have great concern about their poor living conditions affecting general health and adherence to ART. These findings provide guidance for improvement of HIV services and general health care in Malawian institutionalized populations such as prisoners.

Background According to the recent coronavirus disease 2019 (COVID-19) pandemic experience, many emergency departments experience difficulties in responding to emerging infectious diseases and this has led to a public health crisis. Our emergency department (ED) is designed to respond to mass outbreaks of infection. Three major preparations were taken to respond to infectious disease; first, to improve the emergency department facilities; second, to created programs to respond to each phase of an epidemic of COVID-19; lastly, to implemented education and training to promote the safety of medical staff. We would like to share the actual responses and statistics of patients visiting emergency department during COVID-19 periods of pandemic. Materials and methods This research was conducted through a retrospective chart analysis provided by a public medical center with 502 beds since the first report of a COVID-19 confirmed case on January 19, 2020 to June 15, 2020 in Seoul, the capital of Korea. Our emergency department was designed based on Korean Regional Emergency Center Facility Standards, and modified throughout each phases of COVID-19 outbreak. Patients suspected to be infectious are screened in the triage, separating them from general patients, and then receive isolation treatment in isolated wards. Results A total of 4,352 patients visited the ED. 3,202 screenings were conducted with 5 confirmed cases. Another 1,150 patients were treated with general emergent symptoms. There were no problems such as closure of the emergency department or isolation of medical staff while managing COVID-19 confirmed patients. Conclusion Improving emergency department facilities, create an operational program to respond to each phase of COVID-19 outbreak and implement educational programs enabled large number of screening tests and hospitalization for COVID-19 suspected patients while maintaining general medical services. Research in emergency department designs and operational programs should increase to combine research data with better ideas to respond not only during regular periods but also during periods of pandemic.

Purpose This study investigated associations between psychiatric symptom severity and delay in seeking general medical services among individuals with serious mental illness. Methods The association of psychiatric symptom severity, measured by the Positive and Negative Syndrome Scale (PANSS), and general medical care delay was examined among 271 patients at two urban, outpatient psychiatric clinics. Results Higher scores for PANSS paranoid/belligerence were associated with delays in accessing general medical care (adjusted odds ratio [AOR]=1.46, 95% confidence interval [CI]=1.04-2.01, p=.025). Higher scores on the depression symptom cluster were also associated with care delay (AOR=1.43, 95% CI=1.06-1.93, p=.018). Other symptom types showed no associations with care delay. Conclusion Severity of specific psychiatric symptoms was associated with delays in seeking general medical care among people with serious mental illness. Increased focus on psychiatric symptom management may reduce medical care delay, thereby reducing the elevated morbidity and mortality among this population.

Background Teamwork and collaboration are essential to providing high-quality care. Prior research has found discrepancies between nurses’ and physicians’ perceptions in operating rooms, ICUs, and labor and delivery units. Less is known about health care professionals’ perceptions of teamwork and collaboration on general medical services. Methods This cross-sectional study included nurses, nurse assistants, and physicians working on general medical services in four mid-sized hospitals. Researchers assessed teamwork climate using the Safety Attitudes Questionnaire and asked respondents to rate the quality of collaboration experienced with their own and other professional categories. Results Data for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurse assistants) were analyzed. Hospitalists had the highest median teamwork climate score (83.3, interquartile range [IQR] = 72.3–91.1), and nurses had the lowest (78.6, IQR = 69.6–87.5), but the difference was not statistically significant (p = 0.42). Median teamwork climate scores were significantly different across the four sites (highest = 83.3, IQR = 75.0–91.1; lowest = 76.8, IQR = 66.7–88.4; p = 0.003). Ratings of the quality of collaboration differed significantly based on professional category. Specifically, 63.3% (50/79) of hospitalists rated the quality of collaboration with nurses as high or very high, while 48.7% (94/193) of nurses rated the quality of collaboration with hospitalists as high or very high. Conclusion This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals.

Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insur...

The COVID-19 pandemic poses a particular set of challenges for health services. Some of these are common across all services (e.g. strategies to minimise infections; timely testing for patients and staff; and sourcing appropriate personal protective equipment (PPE)) and some are specific to mental health services (e.g. how to access general medical services quickly; how to safely deliver a service that traditionally depends on intensive face to face contact; how to isolate someone who does not wish to do so; and how to source sufficient PPE in the face of competing demands for such equipment). This paper describes how St Patrick’s Mental Health Services (SPMHS) chose to address this unfolding and ever-changing crisis, how it developed its strategy early based on a clear set of objectives and how it adapted (and continues to adapt) to the constantly evolving COVID-19 landscape.

The lidocaine 5% medicated plaster, Versatis®, has one therapeutic indication listed on the Summary of Product Characteristics—symptomatic relief of post-herpetic neuralgia (PHN) in adults. Increased expenditure on Versatis® suggests that there is considerable off-label use. To support the appropriate use of Versatis®, the Health Service Executive’s Primary Care Reimbursement Service (PCRS) introduced a reimbursement application system for Versatis® from 1 September 2017. The aim of this study was to investigate the effect of introducing a reimbursement application system on Versatis® prescribing under the General Medical Services (GMS) scheme. This study was carried out using prescription dispensing data from the PCRS pharmacy claims database. We carried out segmented linear regression to assess changes in the Versatis® prescribing rate per 1000 GMS eligible population, before and after the introduction of the online reimbursement application system. The results of the segmented regression analysis show that there was a statistically significant level (− 4.91, p

Irish medical schools attract an increasingly diverse student population and produce graduates who will practise in many parts of the world. There are particular implications in this for the planning and delivery of the undergraduate psychiatry curriculum. In all countries, mental health services struggle for equitable resourcing, and mental health care within general medical services remains relatively neglected. The traditional undergraduate psychiatry offering has been justifiably criticised for being excessively oriented towards secondary care when the vast majority of medical graduates will pursue careers in primary care or in specialties other than psychiatry. Recently published articles in the Irish Journal of Psychological Medicine address the current challenges and opportunities in providing an undergraduate experience that better prepares students for the mental health aspects of medical practice in a global context. We summarise and discuss these contributions and the recent Royal College of Psychiatrists publication Choose Psychiatry: Guidance for Medical Schools.

Background Mandatory co-payments attached to prescription medicines on the Irish public health insurance [General Medical Services (GMS)] scheme have undergone multiple iterations since their introduction in October 2010. To date, whilst patients’ opinions on said co-payments have been evaluated, the perspectives of community pharmacists and general practitioners (GPs) have not. Objective To explore the involvement and perceptions of community pharmacists and GPs on this pharmaceutical policy change. Methods A qualitative study using purposive sampling alongside snowballing recruitment was used. Nineteen interviews were conducted in a Southern region of Ireland. Data were analysed using the Framework Approach. Results Three major themes emerged: 1) the withered tax-collecting pharmacist; 2) concerns and prescribing patterns of physicians; and 3) the co-payment system – impact and sustainability. Both community pharmacists and GPs accepted the theoretical concept of a co-payment on the GMS scheme as it prevents moral hazard. However, there were multiple references to the burden that the current method of co-payment collection places on community pharmacists in terms of direct financial loss and reductions in workplace productivity. GPs independently suggested that a co-payment system may inhibit moral hazard by GMS patients in the utilisation of GP services. It was unclear to participants what evidence is guiding the GMS co-payment fee changes. Conclusion Interviewees accepted the rationale for the co-payment system, but reform is warranted.

BackgroundPrevious systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution.AimTo explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care.Design and settingA systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as ‘the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional’.MethodThe following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).ResultsSix economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists.ConclusionThere is limited economic evidence for role substitution in primary care; more economic evaluations are needed.

General practice has been increasingly required to expand its role to take on more complex care — demands enabled by the fluid boundaries of what constitutes ‘general practice’. To date, this expansion has largely related to the care of older patients with multiple morbidities; however, medical advances also present increasing opportunities to relocate specific treatments to primary care that have previously been the sole domain of hospital specialists. With the pressures of COVID-19 and yet more proposed NHS reorganisation, is it fair, or even feasible, to expect GPs to take on more responsibility, which may also open them to censure or legal liability? The parameters of ‘general practice’ shift frequently in response to the exigencies of politics, economics, demographics and changing health needs. Descriptions of the GP role are often imprecise, using language such as ‘expert generalist’ and referring to abstract values such as ‘competency’.1 The 2018 Scottish General Medical Services Contract is based on the four principles of ‘contact, comprehensiveness, continuity and co-ordination’ 2 and the English GP contract requires the provision of ‘services’ in broad areas such as ‘chronic disease’,3 but neither is specific to conditions or treatments. This lack of precision may be inevitable for a profession with the title ‘general practitioner’, but while it is difficult, and perhaps unwise, to be prescriptive about every aspect of the role, this leaves general practice more vulnerable than most medical specialties to reorganisation. GPs work increasingly with allied health professionals as well as leading teams of support staff whose roles are similarly being expanded. This presents both opportunities and risks in terms of team-working skills and coordination of care, as well as questions over who should bear ultimate decision-making responsibility for complex cases. Over …

The term ‘acute’ is not synonymous with emergency but this better describes the needs of the 4.42 million children1 (age 0–14 years) who presented to emergency departments in 2017–2018. This huge expansion of ‘emergency’ presentations has taken place relatively quickly (in 2008–2009 there were 2.66 million) and has challenged traditional paediatric services. A decade ago, an unwell child would have presented to their general practitioner (GP) and if necessary referred to see a general paediatrician on an ‘acute’ take. Pathways to emergency care are now much more plentiful, reflecting attempts to both mitigate demand on emergency departments and the emphasis on patient choice in health policy. Attendances for children (age 0–14 years) have remained at about 20% of all emergency presentations for over a decade1; however, short stay admission (less than 24 hours) is becoming the predominant outcome for most referrals.2 While new pathways into the system have opened up (telephone services, urgent care hubs, etc), this has led to regional variation and confusion for parents.3 We still have old models of professional hierarchies which gate-keep access to secondary care and are often dependent on writing letters (although electronically) with little or no focus on prevention. This negates an important continuum emphasised as early as the 1920 Dawson Report (figure 1) and continues to still present a challenge to policymakers today. Figure 1 Extract from the Dawson Report, courtesy of King's Fund. The reasons for these deficits in continuity and comprehensiveness are multifactorial. Certainly, it is likely the UK 2004 General Medical Services contract, which changed out of hours provision, affected care for children along with changing societal expectations in relation to managing simple illness. However, it is also the case that paediatricians have been slow to adapt to the ever-increasing demand for specialist input, advice and/or …

Objectives: To examine the rates of antipsychotic prescribing in the Irish paediatric and young adult population enrolled in the Irish General Medical Services Scheme pharmacy claims database from the Health Service Executive Primary Care Reimbursement Services database, with a focus on age and sex differences. To examine concomitant prescribing of certain other related medicines in this population. Methods: Data were obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive (HSE) – Primary Care Reimbursement Services (PCRS). Participants included children aged Results: Overall the trend in prescribing rates of antipsychotic medications was stable at 3.94/1000 in 2005 compared with 3.97/1000 in 2015 for children Conclusions: While rates of antipsychotic prescribing have decreased or remained stable over the timeframe of the study, we did find a significant proportion of this population were prescribed antipsychotics. This study also shows that co-prescribing of antidepressants increased and highlights the need for guidelines for antipsychotic prescribing in children and youth in terms of clinical indication, monitoring, co-prescribing and treatment duration.

Background The Hadassah Medical Organization operates two hospitals in Jerusalem. During the COVID-19 pandemic it made an administrative decision to operate one hospital as a COVID-19 treatment hospital (CTH) and to have the second function as a non-COVID-19 treating hospital (NCTH) offering general medical services. The purpose of this study was to assess how this decision affected hospital worker anxiety. Methods From April 27 to May 1, during the COVID-19 pandemic in Israel, while the country was under lock-down, an electronic questionnaire survey was carried out among hospital workers of the CTH and NCTH. The questionnaire includes personal demographics and attitudes about COVID-19 and assesses present anxiety state using the State-Trait Anxiety Inventory for Adults (STAI-S) validated questionnaire. A STAI-S score of ≥45 was considered to represent clinical anxiety. Results Completed questionnaires were received from 1570 hospital employees (24%). 33.5% of responders had STAI-S scores ≥45. Multivariable regression analysis showed that being a resident doctor (odds ration [OR] 2.13; 95% CL, 1.41–3.23; P = 0.0003), age ≤ 50 (OR, 2.08; 95% Cl, 1.62–2.67; P P = 0.039), female gender (OR, 1.63; 95% CL, 1.25–2.13; P = 0.0003) and having risk factors for COVID-19 (OR, 1.51; 95% CL, 1.19–1.91; P = 0.0007), but not hospital workplace (p = 0.08), were associated with the presence of clinical anxiety. 69% of the responders had been tested for COVID-19, but only nine were positive. CTH workers estimated that the likelihood of their already being infected with COVID-19 to be 21.5 ± 24.7% as compared to the 15.3 ± 19.5% estimate of NCTH workers (p = 0.0001). 50% (545/1099) of the CTH workers and 51% (168/330) of the NCTH workers responded that the most important cause of their stress was a fear of infecting their families (p = 0.7). Conclusions By multivariable analysis the creation of a NCTH during the COVID-19 pandemic was not found to be associated with a decrease in the number of hospital workers with clinical anxiety. Hospital worker support resources can be focused on the at-risk groups identified in this study.

Non-specific symptoms such as irritability, vomiting, and back arching during the infant period are often attributed to gastroesophageal reflux. While numerous studies have shown no significant benefit to the use of acid suppressant medications in this population, these medications are frequently prescribed in response to these symptoms. Our goals were to understand how often children were being prescribed this medication. To do this, data was extracted from a national database for reimbursement of prescribed medications through the General Medical Services scheme (GMS). Infants aged less than 1 year and eligible for reimbursement under GMS were included for analysis. A total of 450 infants per 10,000 eligible population received an anti-reflux preparation from the following drug classes (H2 antagonists, proton pump inhibitors, or alginate preparations) in 2018. This is compared with that in 2009 where only 137 per 10,000 eligible infants received these medications. This increase was predominantly attributable to an increase in ranitidine prescriptions.Conclusion: Despite a change in clinical guidelines, anti-reflux preparations are increasingly being prescribed to infants aged less than 1 year. The reasons behind the increase in prescriptions containing these medications cannot be ascertained from this data. This may suggest a proportion of these prescriptions may be unwarranted in this population. What is Known: • The prescription of PPIs in infants has increased in a number of countries. • Use of anti-reflux medications has a very poor evidence base in infancy. What is New: • This data focuses only on an infant age group in a "well" cohort. • Ranitidine may contribute to increased acid-suppressant use in infancy.

Background Bipolar disorder (BD) has been associated with greater health morbidity burden, but it is unclear if this association is affected by age at the time of diagnosis and how this might impact on the use of general hospital services. Methods Cross-sectional study investigating the prevalence of common medical morbidities among participants with early (EOBD) and late onset diagnosis of BD (LOBD – age at diagnosis ≥ 60 years) derived from a community-representative sample of 37,183 men aged 65–85 years. Cohort study over a follow up period of up to 17.7 years investigating the hazard of general hospital use among older men associated with EOBD and LOBD taking into account age and prevalent medical morbidities. Results 250 older men had a recorded diagnosis of BD, 75 of whom had LOBD. Diabetes, stroke and diseases of the respiratory and digestive systems were more frequent in men with than without BD. There were no differences in the distribution of medical morbidities between men with EOBD and LOBD. The adjusted hazard ratio (HR) of contact with general hospital services was significantly higher among men with EOBD (HR = 1.33; 95%CI = 1.14, 1.54) and LOBD (HR = 1.27, 95%CI = 1.06, 1.51) compared with older men without BD. Older men with EOBD had the highest number of contacts with general hospital services during follow up, although men with EOBD and LOBD did not differ in the number of contacts due to episodes of mania or depression. The medical reasons for contact with general hospital services of men with EOBD and LOBD overlapped but were not identical. Conclusions Older men with BD experience greater health morbidity than men without BD. Older men with BD access hospital services for the management of physical morbidities earlier and more frequently than men without BD. Age at the time of diagnosis of BD has limited impact on the risk of contact with general medical services, although subtle differences in the physical morbidity of men with EOBD and LOBD warrant further investigation.

Understanding the most common and costly conditions treated by inpatient general medical services is important for implementing quality improvement, developing health policy, conducting research, and designing medical education. To determine the prevalence and cost of conditions treated on general internal medicine (GIM) inpatient services. Retrospective cross-sectional study involving 7 hospital sites in Toronto, Canada. All patients discharged between April 1, 2010 and March 31, 2015 who were admitted to or discharged from an inpatient GIM service. Hospital administrative data were used to identify diagnoses and costs associated with admissions. The primary discharge diagnosis was identified for each admission and categorized into clinically relevant and mutually exclusive categories using the Clinical Classifications Software (CCS) tool. Among 148,442 admissions, the most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). The prevalence of the 20 most common conditions was significantly correlated across hospitals (correlation coefficients ranging from 0.55 to 0.95, p ≤ 0.01 for all comparisons). No single condition represented more than 5.1% of all admissions or more than 7.9% of admissions at any hospital site. The costliest conditions were stroke (median cost $7122, interquartile range 5587–12,354, total cost $94,199,422, representing 6.0% of all costs) and the group of delirium, dementia, and cognitive disorders (median cost $12,831, IQR 9539–17,509, total cost $77,372,541, representing 4.9% of all costs). The 10 most common conditions accounted for only 36.2% of hospitalizations and 36.8% of total costs. The remaining hospitalizations included 223 different CCS conditions. GIM services care for a markedly heterogeneous population but the most common conditions were similar across 7 hospitals. The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts.

Aims The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland. Methods A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated. Results Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P 90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period. Conclusions Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

Every year, a significant number of healthcare workers fall ill with tuberculosis in the Kyrgyz Republic. During the investigated period (2011-2016), 80.8% of all new tuberculosis cases among healthcare workers were registered among nurses, paramedical personnel, and caregivers. Whereby, during the whole period, the part of those who developed tuberculosis in general medical services made 92.8%, while in TB units it was 7.2%.

The current General Medical Services (GMS) contract has been deemed “outdated and inadequate for the current healthcare environment” by representatives at England’s 2021 local medical committee (LMC) conference. A motion proposed by GP Russell Brown from East Sussex LMC and passed in full on 26 November said that General Practitioners Committee England (GPC England) must now negotiate a fee for service contract rather than the current block contract. It added that the new contract should also allow practices to offer private services alongside NHS services, “where such services are not commissioned by the …

Polymorphism of clinical manifestations and absence of pathognomic symptoms are typical of urogenital tuberculosis. Since anti-microbial agents are widely used (fluoruquinolones, amikacin, rifampicin), it is more difficult to verify the diagnosis by pathomorphologic and bacteriological methods. The index of suspicion and certain required minimum level of knowledge on urogenital tuberculosis are crucial for its early diagnostics. Materials and methods . In order to assess the level of knowledge in doctors specializing in different fields (urologists, gynecologists, general practitioners, phthisiologists) about specific symptoms and early diagnostics of urogenital tuberculosis and to evaluate the level of their awareness of this disease, 265 specialists had a test in the form of a questionnaire. To define preferences of specialists when choosing specific therapy of infectious inflammatory disorders of the urogenital system, the answers to the questionnaire given by 2 groups of doctors were analyzed, Group 1 (103 persons) included urologists, gynecologists and phthisiologists from medical units of Novosibirsk Region and city of Novosibirsk, Group 2 (298 persons) included interns and residents of Novosibirsk State Medical University by the Russian Ministry of Health. Results . There was no significant difference between the level of knowledge about urogenital tuberculosis among the specialists: urologists, gynecologists, and general practitioners gave the right answers in 59.2-63.7% of cases; phthisiologists had a better level of knowledge and 77.2% of their answers was right. In every third case, the choice of anti-microbial agents for empiric therapy of acute and chronic cystitis was not the best option regarding the drug resistance and inhibiting action against M. tuberculosis. Conclusion : The results of the questionnaire survey showed the low level of knowledge about urogenital tuberculosis among the specialists of general medical services (urologists, gynecologists, general practitioners). The high number of antibacterial agents with tuberculostatic action which were mentioned as drugs for the empiric treatment of urogenital disorders reflects the fact that importance of urogenital tuberculosis is underestimated by the specialists.

This study examined long-term outcomes (at 36 months) from Washington State's policy of expediting Medicaid enrollment for prison releasees with severe mental illness and compares them with previously reported short-term outcomes (at 12 months).Linked administrative data on prison releasees (2006-2007) were analyzed by using a quasi-experimental design comparing those referred to expedited Medicaid (N=895) with a control group of those not referred (N=2,189). Aggregate outcomes were analyzed with inverse probability of treatment-weighted logit models.Expedited Medicaid had a sustained effect on both increased months of enrollment (p.01) and increased use of community mental health and general medical services (p.01) 36 months after prison release. However, expedited Medicaid did not reduce criminal recidivism, consistent with 12-month findings, Conclusions: Outcome results at 12 months were sustained at 36 months-namely, expedited Medicaid for released prisoners with severe mental illness improved enrollment and service use with no effects on criminal recidivism.

The GP home visit has long been regarded as an integral element of NHS general practice that is needed to support both proactive and reactive care to patients in the community.1,2 There are increasing numbers of people living with multimorbidity and frailty, many of whom have complex healthcare needs and limited levels of social support. Now with the new challenges around providing care at home due to the COVID-19 pandemic, it could be argued that home visits or virtual consultations with patients in their homes are set to become a more essential element of general practice, including in the provision of acute care out of hours. Consulting with patients in their homes provides unique opportunities to develop insights into how illness affects their lives. However, with workloads in NHS primary care rising, and increasing pressures on the GP workforce, the place of home visits in core general practice provision is facing increasing challenge. The requirements of the current GP General Medical Services (GMS) contract in relation to home visiting are broad.3 The contract is not prescriptive about who should visit or where the visit should take place, and states that the decision to visit is dependent on the opinion and agreement of the GP contractor. In November 2019, the Local Medical Committee (LMC) conference debated the current contractual requirements and a motion was narrowly passed to instruct the General Practitioners Committee (GPC) (the negotiating arm of the British Medical …

Background Ireland’s National Clinical Programmme recently produced clinical guidelines on pharmacotherapy for COPD. However, there is no coherent picture of the prevalence of COPD in Ireland, the characteristics of who is receiving medication for COPD and how prescribing aligns with best practice. In view of this, we evaluated medication dispensing data to estimate the age and sex specific prevalence of symptomatic COPD in Ireland, and to identify patterns of medication use which can be used to inform interventions to improve the management of this condition. Methods We used the Primary Care Reimbursement Service database, a national repository of anonymised pharmacy claims for more than 40% of the Irish population who qualify for the General Medical Services (GMS) scheme; a public health insurance programme for those of lower income and those ≥70 years. We used a cohort study design with data from 2016, limiting our population to those aged ≥45 years to help remove dispensing for asthma. We examined the distribution of all respiratory medications dispensed, and then the patterns of medication use in those likely to have COPD. Results From the GMS eligible population (aged ≥45 years) with coverage for the entire year(n=730, 832), there were 170, 950 patients dispensed at least one respiratory medication in 2016; equating to approximately 23% of the GMS population ≥45 years receiving at least one respiratory medication (21.5% of males and 25.0% of females). The prevalence of medication use suggestive of COPD in those aged ≥45 years was 15.1% (m) and 16.2% (f). Prevalence was higher in females than males aged between 45 and 64 years (13.1% vs. 10.1%, p Conclusion The prevalence of medication use consistent with the management of symptomatic COPD mirrors international estimates on prevalence of COPD, and in the absence of a population-based prevalence study, can be used to inform decision making. The high use of ICS, and the under use of LAMA therapy and poor adherence of those newly initiated is of concern. We recommend the development of an educational intervention for health professionals to assist in the implementation of new national prescribing guidelines for the management of COPD.

The acute hospital system in the NHS is in crisis, with the rising demands of treating elderly comorbid patients and limited financial and workforce resources. An increase in the workforce trained in and delivering general medical services seven days per week has been proposed as a solution to this crisis. The current trainee and consultant workforce is unable to provide this increase because of imbalances between training and service delivery, the different demands of large and small hospitals and the need to simultaneously provide high-quality specialised services. The demographics of the NHS medical workforce are also changing, which will limit expansion. It is very unlikely that a generalist workforce can be achieved in less than 10 years without a clear governmental strategy and increased staffing levels, both of which seem unlikely at present.

Background The Drug Burden Index (DBI) quantifies exposure to medications with anticholinergic and/or sedative effects. A consensus list of DBI medications available in Ireland was recently developed for use as a DBI tool. The aim of this study was to validate this DBI tool by examining the association of DBI score with important health outcomes in Irish community-dwelling older people. Methods This was a cohort study using data from The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data. Individuals aged ≥65 years participating in TILDA and enrolled in the General Medical Services scheme were eligible for inclusion. DBI score was determined by applying the DBI tool to participants’ medication dispensing data in the year prior to outcome assessment. DBI score was recoded into a categorical variable [none (0), low (> 0 and

Details of the latest General Medical Services contract for general practitioners (GPs) in England were released on 31 January with implementation due to take effect from April 2019.1 At a time when general practice is struggling to cope with higher, more complex demands and a diminishing workforce, it is seen as a last chance to redevelop GP services in England and to do things differently.2 Broadly speaking, the 5-year framework includes a large injection of funding for primary care with much of it contingent on participation in primary care networks (PCNs).3 The development of PCNs unlocks money for additional staff including, in the first year, clinical pharmacists and social …

ObjectivesThe aim of this study was to explore the extent of implementation of the General Medical Services 2018/2019 ‘frailty identification and management’ contract in general practitioner (GP) practices in England, and link implementation outcomes to a range of practice and Clinical Commissioning Group (CCG) factors.DesignA cross-sectional study design using publicly available datasets relating to the year 2018 for all GP practices in England.SettingsEnglish general practices.DataThe analysis was conducted across 6632 practices in 193 CCGs with 9 995 558 patients aged 65 years or older.OutcomesFrailty assessment rates, frailty coding rates and frailty prevalence rates, plus rates of medication reviews, falls assessments and enriched Summary Care Records (SCRs).AnalysisSummary statistics were calculated and multilevel negative binomial regression analysis was used to investigate relationships of the six outcomes with explanatory factors.Results14.3% of people aged 65 years or older were assessed for frailty, with 35.4% of these—totalling 5% of the eligible population—coded moderately or severely frail. 59.2% received a medications review, but rates of falls assessments (3.7%) and enriched SCRs (21%) were low. However, percentages varied widely across practices and CCGs. Practice differences in contract implementation were most strongly accounted for by their grouping within CCGs, with weaker but still important associations with some practice and CCG factors, particularly healthcare demand-related factors of chronic caseload and (negatively) % of patients aged 65 years or older.ConclusionCCG appears the strongest determinant of practice engagement with the frailty contract, and fuller implementation may depend on greater engagement of CCGs themselves, particularly in commissioning suitable interventions. Practices understandably targeted frailty assessments at patients more likely to be found severely frail, resulting in probable underidentification of moderately frail individuals who might benefit most from early interventions. Frailty prevalence estimates based on the contract data may not reflect actual rates.

Objective:To promote integrated general medical care for individuals with serious mental illness, the New York State Office of Mental Health (OMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This study examined clinics’ enrollment in this program to understand its potential to reach individuals with serious mental illness.Methods:Information on enrollment and characteristics of clinics (N=500) was obtained from OMH administrative databases. Clinic enrollment in the HM/HP program was examined for the program’s first five years (2010–2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment.Results:A total of 291 of 500 (58%) licensed clinics in New York State in 2015 enrolled in the HM/HP program, potentially reaching 62% of all Medicaid enrollees with serious mental illness seen in specialty mental ...

Noncompliance is a common behavior problem exhibited by typically developing children, as well as individuals with intellectual disabilities, and is correlated with a number of psychiatric diagnoses later in life. We begin this manuscript by describing the definition and prevalence of noncompliance. We then review the assessment procedures that can be used to identify the variables contributing to noncompliance among children. Finally, we describe recent research on both antecedent and consequence-based treatments for noncompliance. A number of specific interventions, including advance notice, the high-p instructional sequence, prompting precursor behaviors, guided compliance, and differential reinforcement, are highlighted. Throughout the review, we provide specific recommendations for practice. Keywords: assessment, compliance, noncompliance, treatment ********** Noncompliance is defined as doing anything other than what has been requested by a parent or other adult authority figure within a specific time frame (Kalb & Loeber, 2003). Compliance is the inverse of this definition. Although the term noncompliance does not pass the dead man's test (i.e., "if a dead man can do it, it's not behavior"; Malott & Suarez, 2004, p. 9), it has a long history of use and will, therefore, be described in this review. Persistent noncompliance is correlated with a number of psychiatric diagnoses later in life (Kalb & Loeber, 2003), and has been consistently rated as a primary reason for referral by parents who seek outpatient behavioral or mental-health services (McMahon & Forehand, 2003). Even at pediatrician's offices, where parents seek general medical services, noncompliance is often a parent's top concern (McMahon & Forehand, 2003). Furthermore, noncompliance may be even more worrisome for parents of children with special needs (e.g., autism spectrum disorders) because it is correlated with poor academic progress among these children (Wehby & Lane, 2009). Finally, noncompliance is important because learning to comply with instructions is regarded by many as a behavioral cusp (Bosch & Fuqua, 2001), in that it is a skill that makes learning other skills possible. A post-instruction interval is typically included in the definition of compliance, which describes when children must initiate a response for their behavior to be considered compliant (Forehand, Roberts, Doleys, Hobbs, & Resick, 1976). Wruble, Sheeber, Sorensen, Boggs, and Eyberg (1991) analyzed the behavior of 15 nonreferred preschool children-mother pairs during parent-directed interaction and cleanup. The experimenters determined that on 85% of opportunities, children initiated compliance within 5.4 s of the parental instruction, and suggested the time of 5.4 s as the threshold for a child to be considered compliant. A more recent study by Shriver and Allen (1997) used procedures similar to Wruble et al. (1991), albeit with both referred (i.e., children who have received behavioral health services) and nonreferred children-mother pairs, and identified average initiation latencies of 5.9 s for the total sample, 5.4 s for referred children, and 6.71 s for nonreferred children. Taken together, the results from Wruble et al. (1991) and Shriver and Allen (1997) underscore the difficulty in determining a standard initiation latency for compliance. Due to this, many authors now use 10 s as the post-instruction interval. Although the prevalence of noncompliance has not been well documented, estimates suggest it is common. A review by Kalb arid Loeber (2003) estimated the prevalence of noncompliance in children and adolescents to be between 25% and 65%. Approximately 50% of parents of nonreferred 4- to 7-year-olds report noncompliance at home and approximately 85% of parents of referred 4- to 7-year-olds report noncompliance at home (McMahon & Forehand, 2003). These data suggest that noncompliance is ubiquitous, particularly among young children. …

Primary and Behavioral Health Care Integration (PBHCI) grants aim to improve the health of people with serious mental illness by integrating primary and preventive general medical services into behavioral health settings. This report describes the general medical outcomes of persons served by early cohorts of programs, funded in 2009 or 2010, that participated in this national demonstration project.A quasi-experimental, difference-in-differences design was used to compare changes in general medical health among consumers served at three PBHCI clinics (N=322) and three clinics that were selected as matched control sites (N=469). Propensity-score weighting was used to adjust for baseline differences between PBHCI and control clinic populations. Baseline data were collected between 2010 and 2012; follow-up data were collected approximately one year later. General medical outcomes included blood pressure; body mass index; cholesterol, triglyceride, and blood glucose or HbA1c levels; and self-reported tobacco smoking.Compared with consumers served at control clinics, PBHCI consumers had better outcomes for cholesterol: mean reductions in total cholesterol were greater by 36 mg/dL (p.01), mean reductions in low-density lipoprotein cholesterol were greater by 35 mg/dL (p.001), and mean increases in high-density lipoprotein cholesterol were greater by 3 mg/dL (p.05). No significant PBHCI effects were observed for the other health indicators.Approximately one year of PBHCI treatment resulted in statistically and potentially clinically significant improvements in cholesterol but not in other general medical outcomes examined. More rigorous implementation of integrated care in community behavioral health settings may be needed to further improve the health of adults with serious mental illness.

Background: Uganda’s government embraced private provision of social services including health care. The involvement of private providers is an indicator that the public facilities are not sufficient enough to meet the high demands of the ever-increasing population. This has been done through partnership arrangements. This paper discusses the impact of Public-Private Partnership (PPP) on health care outcomes of the local population and opportunities for improving health outcomes, challenges facing private providers in a low-income setting like Uganda. Methodology: This was a qualitative study, data were collected using qualitative methods in January 2017 through interview (using semi-structured questions) at Ruharo Mission Hospital (RMH) administration, health workers, district health office and used a structured questionnaire for patients/clients. This was a nascent study, with a sample size of 22 respondents. The hospital has three departments; Organized Useful Rehabilitation Services (OURS), General Medical Services (GMS) and Eye Department (ED). All the departments of the hospital were represented in this study. Results: The hospital is a Church of Uganda founded, and runs a budget of 5 billion shillings ($ 1,351,351.4) annually, has multiple sources of funding including PHC funding annually and that, health services were delivered adequately to clients. Much as some services were accessed at no costs, other services like eye treatment were found expensive on the side of clients. The hospital’s hybrid mode of delivering health services through outreaches and facility-based services was cherished, however it had no ambulance and relied only on a hospital van. Conclusions and Recommendations: Our study concludes that if private providers are supported under the partnership arrangement, they can adequately deliver services to the clients and decongest the public facilities. We recommend that the government devote more funds to support the hospital through employing more sub-seconded staff, procuring medicines, and ambulances to enable it to subsidize services especially eye treatment and other services not supported under the partnership.

Optimising child health in general practice is a key health service priority. In Ireland, where 23% of Ireland’s population are aged under 16, GP consultations have historically involved a private fee or have been covered by Ireland’s General Medical Services (GMS) scheme. In July 2015, this scheme was expanded so that free GP care was provided to all children aged under 6 years. Recent research suggests this change in policy has led to a substantial increase in the number of children under six attending both daytime and out-of-hour GP services and highlights a need to better understand the perspectives of GPs on this policy change. To address these knowledge gaps, this paper aims to examine GPs’ views on the scheme and how it has impacted on their practice. Sixteen GPs participated in semi-structured telephone interviews between June and August 2016, analysed using inductive thematic analysis. Six key themes were identified: (1) increased service utilisation, (2) changes in parental behaviour when accessing services, (3) increased ‘out of hours’ service utilisation, (4) dissatisfaction with the current resourcing of the scheme, (5) limited capacity to support expansion of free GP care, and (6) reduced antibiotic prescribing. The study highlights how introducing free GP care to a mixed private/publicly funded health system may impact on GP workload, parents’ interaction with services and physician practice.

Part I. Psychiatric epidemiology and general practice: the development of a research field. 1. The science of epidemiology: empirical data gathering, public health action, or both? L. Eisenberg . 2. Psychiatric illness, epidemiology and the general practitioner B. Cooper . 3. The 'reserach magnificent' comes of age M. M. Shepherd . 4. Primary care and psychiatric epidemiology: the psychiatrist's perspective D. Goldberg and L. Gask . Part II. Psychiatric field surveys in the primary health care setting: an international perspective. 5. Psychiatric morbidity in general practice: a community wide perspective A. Richman . 6. The epidemiological basis for mental health care as a part of primary health care: a case for action M. Kramer, B. Lima, E. Simonsick and I. Levav . 7. Psychiatric illness and services in a UK Health Centre B. Jarman . 8. Psychological complaints in general practice: a national survey in the Netherlands PFM. Verhaak, J.M. Bosman, M. Foets and I. van der Velden . 9. Psychiatric morbidity and physical illness among general practice patients in Cantabria, Spain J.L. Vazquez-Barquero . 10. Medical disorders in primary care in a health district of Bahia, Brazil N. de almeida-Filho, V.S. Santana, E.C. Moreira, M.G. Modesto and M.B. Oliveira . 11. Use of health services by homeless and disaffiliated persons with severe mental disorders: a study in Melbourne H. Herrman, P. McGorry, K. Varnavides and B. Singh . Part III. Psychiatric and general medical services: issues of patient selection, referral and treatment. 12. the relationship of usual source of health care to the prevalence of psychiatric disorder and utilisation of ambulatory mental health services in the USA M.L.Bruce, G.L. Tischler and P.J. Leaf . 13. Care of mental health problems in Finland: selection between primary medical and psychiatric specialist services V. Lehtinen, M.Joukamaa, E. Jyrkinen, K. Lahtela, R. Raitasalo, J. Maatela and A. Aromaa . 14. Psychiatric morbidity in general practice in Verona: the importance of parallel studies at the primary and specialist levels of health care M. Tansella, C. Bellantuono and P. Williams . 15. Prescribing of psychotrophic drugs by primary care physicians and psychiatrists: a study in Iceland T. Helgason . Part IV. Late-life mental disorders and primary health care. 16. Late-life mental disorders and primary health care: a review of research B. Cooper . 17. Prevelence and one-year course of dementia in an English city: in application of "CAMDEX" D.W. O'Connor and P.A. Pollitt . 18. Cognitive disorders among elderly general-practice patients in a West German city H. Bickel . 19. Dementia: case ascertainment and health utilization in a US rural community M. Ganguli, L.H. Kuller, S. Belle, G. Ratcliff, F.J. Huff and K.M. Detre . Part V. Problems of method: case-finding, classification and texonomy. 20. Identification of psychiatric cases in primary health care settings: the utility of two-phase screen...

Mental health problems continue to be a significant comorbidity for people with HIV infection, even in the era of effective antiretroviral therapy. Here, we report on the changes in the mental health diagnoses based on clinical case reports amongst people with HIV referred to a specialist psychological medicine department over a 24-year period, which include the relative increase in depressive and anxiety disorders, often of a chronic nature, together with a decline in acute mental health syndromes, mania, and organic brain disorders. In addition, new challenges, like the presence of HIV and Hepatitis C co-infection, and the new problems created by recreational drugs, confirm the need for mental health services to be closely involved with the general medical services. A substantial proportion of people with HIV referred to specialist services suffer complex difficulties, which often require the collaboration of both psychiatrists and psychologists to deal effectively with their difficulties.

In 2008, the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans' early responses to MHPAEA (after its 2010 implementation), in terms of both intended and unintended effects.Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate).Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network.The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.

Background Demand for inpatient beds is increasing whilst supply is diminishing. General medical services are feeling this demand as the ageing population presents more patients with undifferentiated illness traditionally cared for by this service. Redesign efforts need to focus on improving the quality and speed of decision-making to utilise resources efficiently. Aims The aim of this study was to improve patient flow through general medical services by undertaking a comprehensive redesign process targeting each stage of the patient journey. Methods We utilised a rapid improvement event to identify waste and design a new model of care (MOC) that eliminated as much waste as possible. The model had three main elements: (i) ward-based teams; (ii) 7-day per week standard work; and (iii) pull systems to operate for all transfers and referrals. Here, we analyse the first 12 months of the new MOC with regard to key outcomes: length of stay, occupancy, weekend discharges, clinical incidents and Medical Emergency Team (MET) calls, emergency department length of stay and National Emergency Access Target (NEAT) performance and elective surgical throughput. Results The new MOC resulted in a 0.88-day reduction in length of stay. This resulted in reduced general medical bed occupancy of 19 beds. Weekend discharges improved by 54.6%. There were no significant increases in serious clinical incidents or MET calls. Emergency department admitted NEAT performance improved also. Conclusion Redesign of the general medicine model of care eliminating waste has resulted in a significant improvement in patient flow and reduced length of stay without compromising quality of care.

Princess Mother’s Medical Volunteer (PMMV) Foundation is the most recognized and significant free-of-charge mobile medical service (MMS) provider in Thailand. They require volunteers from partner hospitals to give medical care to poor populations residing in remote areas of the country where access to general medical services is limited. Volunteers usually include four types of staff: doctors, dentists, nurses, and pharmacists. According to their operational plan, the PMMV and their working partners need to properly allocate/assign volunteer medical staff to operation sites according to site requirements. In current planning process, the PMMV has to organize massive amounts of data from different organizations in the country, resulting in a long processing time for allocation decisions. In addition, the current process does not allow decision makers to efficiently allocate medical staff with acceptable transportation cost. There is a significant opportunity to improve this process by using analytical models to support this decision making. Thus, this paper proposes a decision support model for staff allocation. The proposed model is in a form of computer information system (CIS) that is carefully developed to facilitate the access to heterogeneous data and ease of use by decision makers. The proposed CIS will assist the PMMV central offices and partners to manage massive data more efficiently and effectively, while the decision algorithm can facilitate planners to achieve the lowest possible cost associated with their decisions. The outcomes of this research were verified by potential users through a focus group manner. The result showed that the potential users were very satisfied with the overall performance of this system.

BACKGROUND Failures in communication at the time of patient handoff have been implicated as contributing factors to preventable adverse events. OBJECTIVE Examine the relationship between face-to-face handoffs and the rate of patient outcomes, including adverse events. DESIGN Retrospective cohort. SETTING A 1157-bed academic tertiary referral hospital. PATIENTS There were 805 adult patients admitted to general internal medicine services. INTERVENTION Retrospective comparison of clinical outcomes, including the rate of adverse events, of patients whose care was transitioned with and without face-to-face handoffs. MEASUREMENTS Rapid response team calls, code team calls, transfers to a higher level of care, death in hospital, 30-day readmission rate, length of stay, and adverse events (as identified using the Global Trigger Tool). RESULTS There was no significant difference with respect to the frequency of rapid response team calls, code team calls, transfers to a higher level of care, deaths in hospital, length of stay, 30-day readmission rate, or adverse events between patients whose care was transitioned with or without a face-to-face handoff. CONCLUSIONS Face-to-face handoff of patients admitted to general medical services at a large academic tertiary referral hospital was not associated with a significant difference in measured patient outcomes, including the rate of adverse events, compared to a non–face-to-face handoff. Additional study is needed to determine the qualities of patient handoff that optimize efficiency and safety. Journal of Hospital Medicine 2015;10:137–141. © 2015 Society of Hospital Medicine

The study explored the association of delays in seeking general medical care with elevated blood pressure and metabolic abnormalities among individuals with serious mental illness.Association of delays in medical care with blood pressure, serum hemoglobin A1c (HbA1C), and lipids was assessed among patients at two inner-city community mental health centers.Of 271 participants, 62% reported delays in seeking general medical care due to attitudinal and financial barriers. Care delay was associated with abnormalities in measured blood pressure (adjusted odds ratio [AOR]=2.14, p=.029) and HbA1c (AOR=3.18, p=.026). Care delay was not associated with abnormalities in lipid profiles.This study found that delays in seeking general medical care are common and are associated with clinical markers linked with common medical conditions. The results may help to explain the elevated morbidity and mortality associated with serious mental illness.

Less is known about the experiences of older adults (65+ years of age) with co-occurring mental health and alcohol and other drug use disorders (dual diagnosis) than is known about the experiences of their younger counterparts. This exploratory qualitative study sought to interview individuals receiving case management from an inner Melbourne community mental health service to determine their experiences of living with dual diagnosis and explore their interactions with mental health and addiction treatment, and general medical services alike. Six older adults with a dual mental health and substance disorder agreed to participate in a semi-structured interview process and provided their perspectives about living with complex mental illness and alcohol and other drug use. Several key themes emerged throughout the interview process, mirroring the notion of dual diagnosis being a complex phenomenon involving a number of interrelated factors: these include medical complexity, poor service engagement and long-term use of alcohol and other drugs. Interviews also demonstrate the challenges inherent in providing care to this cohort, with the participants frequently describing their experiences with services as being fraught with difficulty. The increased understanding of the perspectives of older adults with dual diagnosis provides the foundation for further research into this population in addition to influencing future nursing care provided to this cohort.

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self-regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four-part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer-based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer-led mutuality and externally led comptrol.

This chapter aims to achieve maximum Quality and Outcomes Framework (QOF) points. The value of each point is determined by the prevalence. The prevalence could be low because of poor communication with your patients, no or a poor system to review practice records or an inaccurate data entry. When the general medical services contract was introduced in 2004, General Practitioners leaders agreed that QOF pay should be adjusted to account for prevalence. They argued that practices with three times the prevalence had three times the work and deserved three times the reward. All new patients, including those in nursing and residential homes, registering with the practice must be added to the disease specific register. Educate the patients; explain the real risks of not complying with medication and attending regular follow-ups. It is easy to make mistakes in coding. A small error in coding can lead to lost money.