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Supporting People with Long Term Conditions4 based its improvement programme on models from the USA (Kaiser Permanente buy cheap nasonex nasal spray on-line allergy symptoms 36, Pfizer and Evercare) discount 18gm nasonex nasal spray free shipping allergy forecast san francisco ca. These models are based on nurses acting as case managers who have a key role in co-ordinating services from other health and social care providers discount nasonex nasal spray 18 gm line allergy testing for dogs cost. The RCGP promotes care planning,15 but acknowledges that coexisting mental and social circumstances may prevent such approaches. There are few validated tools for such assessment, especially for use by nurses. The development of interventions for primary care that encourage holistic assessment and action to address complex health and social needs is urgently required. Depression screening in LTCs has now been removed from the QOF, but patient and carer groups have argued that this will serve only to remove the imperative to include assessing mental health needs in LTCs. The National Institute for Health and Care Excellence (NICE) now recommends that a biopsychosocial assessment is carried out, but only for patients newly diagnosed with depression, and it provides little guidance on how this should be addressed and no imperative to act on this assessment. The tool encourages linking with other sectors to more appropriately address these problems for patients and to access alternative types of resources. The PCAM tool also encourages new ways of working that enhance opportunities for health promotion, even in those with few current health or social problems, to maintain healthy behaviour. It is anticipated that this will lead to improved quality of life for patients and better patient–professional interactions and relationships. The PCAM tool is an adapted version of the Minnesota Complexity Assessment Method (MCAM), which 17–19 was derived from the INTERMED (a method to assess health service needs). The PCAM has previously been evaluated in anticipatory (Keep Well) health check clinics, which were initiated by the Scottish Government for early identification of LTCs, or risk of LTCs, in those aged 40–64 years and living in deprived communities in Scotland. The PCAM tool may also provide a more systematic approach for primary care in responding to the NICE and RCGP recommendations for biopsychosocial assessment of patients with LTCs and/or depression. There is strong potential for the PCAM tool to make a real difference to the quality of care delivered in primary care to patients living with LTCs. The PCAM tool aims to encourage nurses to address more than just the physical care needs of their patients, or at least to determine these needs for others to address. By addressing these needs, patients could be better positioned to engage with health promotion and self-care advice and should also see improvements in their physical and mental well-being. There is also a strong potential for the PCAM tool to result in a greater range of services and support being enlisted in the care and support of those with LTCs, and especially for those patients from disadvantaged communities. This has the potential to reduce the burden on the NHS as the main or sole provider of care and support for many of these patients, who often end up with repeat hospitalisations and high levels of primary care use. It is also hoped that it will result in greater integration of health and social care needs and the co-ordination of meeting these needs, and that use of the PCAM tool can result in greater use of community and voluntary sector resources, as was demonstrated in the Keep Well evaluation in Scotland. This research also aimed to determine whether or not a future full-scale randomised controlled trial (RCT) is feasible and whether or not the methods proposed for such a trial are acceptable, with the aim of developing a research protocol and application for funding for such a trial. Aims l To assess the acceptability and implementation requirements of the PCAM tool for use in UK primary care, particularly in the context of PN-led annual reviews for people with LTCs. Research questions Overall, this study sought to answer the following two main questions: 1. Is it feasible and acceptable to use the PCAM tool in primary care nurse-led annual reviews for those with LTCs? Is it feasible and acceptable to run a cluster randomised trial of the PCAM intervention in primary care? The pilot trial aimed to answer the following questions: 1. Can we recruit practices and nurses to take part in the study and retain them? Can the practices and nurses implement study procedures correctly? Are patients willing to complete questionnaires/outcome measures? How many missing data are there, and does this relate to nurse- or patient-level follow-up? What estimates of effect size, variance and likely intracluster correlation coefficient (ICC) should be used to inform the sample size of the full study? Should the unit of analysis be at the nurse or patient level, or is it feasible or necessary to include both? This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 3 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. INTRODUCTION, BACKGROUND AND AIMS Objectives l To conduct focus groups with primary care staff and patients with LTCs to assess acceptability and implementation requirements. Structure of the report The research is reported as five related research studies (studies A to E). Chapter 2 provides an overview of the overarching study design and conceptual framework for the research, and the general methodological approach to each of the individual studies. Chapter 2 also reports on the general management and conduct of the research, including ethics approval and patient and public involvement (PPI). Chapters 3–7 report on each of the separate studies (A–E), including their methods, findings/results and a discussion of the findings and conclusions. Chapter 8 presents on overall discussion, including the strengths and limitations of our work, a reflection on our PPI and summary conclusions and recommendations. The purpose of the PCAM tool was to provide a practical but systematic vocabulary and action-based evaluation system that could be applied to a primary care setting to improve the care, and self-care, of patients with multiple (complex) needs. An early version, the MCAM, was developed in the USA for use by clinical teams (doctors and nurses) for the case management of patients with medically unexplained symptoms. This has been undertaken by the current team in the context of adapting it for use in Keep Well health screening consultations. This resulted in the development of the PCAM, as an adapted version of the MECAM, for use in the UK. It was successfully implemented and evaluated with seven Keep Well nurses, and was shown to increase non-medical referrals, especially to psychological, social and lifestyle referrals. The PCAM tool is also in use in the USA, where it is undergoing further testing. It was therefore a reasonable theoretical assumption that the PCAM tool could be of value for primary care nurse engagement with the mental and social well-being of their patients with LTCs who are at higher risk of poor mental health and social problems. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 5 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. OVERVIEW OF STUDY DESIGN, METHODOLOGY AND GENERAL MANAGEMENT with more time available at each consultation. The PCAM intervention had not been reviewed by GPs or PNs, and neither had its usability and acceptability been evaluated in primary care.

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Hence purchase nasonex nasal spray 18 gm allergy testing queanbeyan, these cases offer clues to the nature of clinical leadership and thus they point to lessons from which others can learn – whatever the particular institutional form might happen to be purchase nasonex nasal spray 18gm amex allergy symptoms checker. In order to facilitate cross-case comparisons cheap nasonex nasal spray 18 gm online allergy symptoms pollen headache, each case write-up is structured in accordance with a standard framework: the context within which the CCG operates; an account of the service redesign attempt being studied; emerging insights about clinical leadership; and the overall lessons and conclusions from the case. Systematic cross-case comparisons are made in the following chapter. The analytical framework Drawing on the findings from the 15 scoping CCGs in phase 1 and the findings from the two national surveys, we were aware that clinical leadership in service redesign was being enacted in different arenas. These arenas may be temporary and sporadic or relatively stable. Crucially, in a health service context where there are multiple overlapping organisations and professional groups that periodically come together or are brought together, the arena is a realm of interaction. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 37 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE CASE STUDIES were investigating, influence extended in varying degrees across organisational boundaries, across formal lines of authority and across looser informal groupings. In and around CCGs it appears that clinical leadership was located in each of our eight case studies in three main types of arena. One of these arenas was at the strategic, policy-making level, typically located at the CCG governing body, but sometimes also involving other strategic bodies above this level. A second was found in the setting of programme boards and similar bodies responsible within a CCG for the operational commissioning of particular groups of services. A third was in the delivery setting, where clinicians involved in providing innovative services worked on the operational and practice aspects. Figure 24 displays these types of arenas in a schematic way. The depiction of three different kinds of arena as points of a triangle containing clinical leadership is intended to convey a richer understanding, beyond the idea that there is a hierarchy of clinical inputs corresponding to a hierarchy of NHS authority. Our cases demonstrate that clinical leadership is needed in each of these arenas, but that the system works in an interdependent way. The relationships between the arenas are constructed through a mix of collegial, professional network mechanisms and market relationships, as well as, indeed rather more than, through hierarchical command and control relationships. The first arena for the potential exercise of clinical leadership (point 1 of the triangle in Figure 24)was concerned with the development of service priorities for the whole population living within a defined geography and with the strategic approach to meeting these priorities. In the original conception of CCGs, this strategic arena was the governing body of a CCG. This is where GPs and others were originally meant to be making a difference. They were to be allocated a budget to meet the needs of a population and expected to proceed with the whole commissioning cycle, including assessing need, reviewing service provision, deciding priorities, designing services, shaping the structure of supply, planning capacity and managing demand, managing performance and seeking public views. From the cases studies we found that practice was rarely quite so systematic. Opportunistic funding and, in some cases, financially straitened circumstances intervened. We found that, in three of our eight cases, tasks in this strategic arena were undertaken by clusters of neighbouring CCGs acting in concert. In one case this was a collaboration between all CCGs active within a county-wide footprint. In another case the strategic work to redesign integrated services for the elderly and those with more severe long-term conditions was done at the level of a collaboration of four neighbouring CCGs working together with their LAs. Yet, in a third case the dominant strategic arena was a collaboration between the CCG and a coterminous LA. In all cases there was a drift towards, and pressure towards, shifting some strategic issues to a higher level, such as strategic reference groups and STPs. CCG board, STP) (2) Operational commissioning arena (3) Practice/delivery FIGURE 24 Three arenas of clinical leadership. Strategic clinical inputs of this nature can be seen as paving the way for further and rather different modes of clinical leadership needed to produce service redesign, in the second and third kinds of arena. At the same time, we found that this strategic level of commissioning leadership was perhaps less emphatically provided by clinicians than might have been expected from the original aspirations attached to CCGs. Professional managers, with support from CSUs, were likely to be attempting at least some of this. The second arena (point 2 on the triangle) allowed the exercise of clinical leadership in the matters of operational commissioning. These bodies were allocated the responsibility for progressing tranches of work by the CCG, each typically concerning delivering services addressing broad categories of health need, such as mental health, urgent care, or care for the frail and elderly. The programme boards sought to bring together key stakeholders. Their remit was to review current provision and identify problems and gaps in that provision, to shape initiatives, develop detailed policies, recommended contracts and monitor performance. In the cases we followed, there was evidence of work within the tradition of collaborative supply chain activity; provider clinicians as well as GP commissioning leads for the area concerned were represented on these boards and were in a position to bring to the table both the legitimate concerns about viability being experienced by providers and ideas for how to deliver services more cost-effectively. Collaborative, clinically informed discussions about the best way of meeting needs could then provide the basis for formal contracts between the CCG and provider organisations, which the programme board would then monitor and manage. It is also where we found much of the PPI taking place. The implementation and practice arena is hugely important because grand plans would count for little if GPs, community and acute clinicians failed to respond to and enact the new ways of working called for by their colleagues in commissioning roles. Indeed, all of our cases in some way illustrate that this work at the sharp end was where most work needed to be accomplished. Although individual provider clinicians had key roles in fleshing out the detailed clinical practices, our cases also revealed the importance of new collaborative forums for working out operational detail in integrated services. We found fascinating examples of learning occurring between different acute providers. We also saw the creation of practice networks in primary care, where learning was shared between practices about how to improve services and standards. Peer pressure, peer-to-peer role modelling, the development of a shared moral ethos and mutual learning were all vital, especially in such instances. In some cases, this arena of service delivery leadership extended beyond primary and acute health service providers and took in additional service providers, such as adult social care, housing and employment support. An essential point of Figure 24 is that clinical leadership is exercised in different arenas and depends on different capabilities. Clinical expertise and experience had important distinctive roles to play in each arena. However, there were also crucial interconnections, grounded in the nature of clinical expertise and experience. Clinical perspectives served as an important integrative mechanism.