• Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'

      Quinlivan, Leah; Nowland, Rebecca; Steeg, Sarah; Cooper, Jayne; Meehan, Declan; Godfrey, Joseph; Robertson, Duncan; Longson, Damien; Potokar, John; Davies, Rosie; et al. (2019-06-13)
    • Creating a safety net for patients in crisis: paramedic perspectives towards a GP referral scheme

      Blodgett, Joanna M; Robertson, Duncan; Ratcliffe, David; Rockwood, Kenneth (2017-01)
      Abstract published with permission. An innovative policy implemented by a UK Ambulance Service allows paramedics to refer patients to a GP Acute Visiting Service scheme. Initial evidence suggests that this alternate route of care can decrease hospital admission rates, decrease A&E waiting time and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that are not captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic's perspective. All notes were transcribed, coded and analysed using a Grounded Theory approach. Four main themes emerged: 1) barriers to referral including wait time, process, and lack of confidence, experience and training 2) approaching the patient with the GP referral scheme in mind 3) frustrations with GP decision making and 4) awareness/understanding of the scheme's impacts. This study provided valuable insight into the paramedic's perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP's perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success.
    • Frailty as lived, frailty as applied: exploring lived experiences in older patients who have fallen and called 999

      Robertson, Duncan; Cooke, Mary (2016-09)
      Rationale The aim of this pilot study was to explore the personal meanings of frailty within a purposive sample of older patients who had fallen, needed an Emergency Ambulance Service response and were subsequently referred to a falls service. A systematic literature review indicated that no qualitative studies had been carried out within such a sample previously. Methods The qualitative methodology used Interpretative Phenomenological Analysis; which explored the essential nature of frailty as a phenomenon though a series of subjective narrative accounts generated by focused interviews. Employing a reflexive approach to the analysis allowed completion of a participant-centred and ethically sound study. Results Analysis of six focused interviews with older adults provided a thick description which highlighted five themes: Adaptations to frailty, Focus on confidence as psychological frailty, A changing lifeworld-towards social frailty, Reconciling a frail future and Frailty as stigma. These themes were discussed in relation to sociological literature including theories concerning transitions from the third to fourth age, liminality and social death, frailty as stigma and frailty as lived and frailty as applied. Implications This sample of patients represented a group in transition. They occupied a liminal zone situated between the third and fourth age and while acknowledging oldness, they actively challenged biomedical assumptions of frailty through an emphasis on control and individual agency. This study enables paramedics to modulate their communications when encountering elders who reject the notion of frailty as a term applied. For service design, the results allow the voice of the patient group to be heard, so that solutions can be designed in an inclusive, rather than hierarchical fashion. Significantly, this thesis forms part of an emerging body of evidence that questions the usefulness of the term frailty as experienced by this sample of participants. https://emj.bmj.com/content/emermed/33/9/e11.1.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2016-206139.35
    • Paramedic perspectives towards gp referral schemes in north west England: a qualitative-observational study

      Blodgett, Joanna M; Robertson, Duncan; Ratcliffe, David; Rockwood, Kenneth (2017-10)
      Background An innovative policy developed and implemented by a UK Ambulance Service allows paramedics to refer patients to the GP Acute Visiting Service scheme. Initial evidence suggests that using this alternate route of care can decrease hospital admission rates, increase bed availability, decrease wait time in A and Es and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that have not been captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic’s perspective. Methods We observed eight paramedics throughout full shifts of 8–12 hours. Data was collected using participant demographics, researcher observations and informal semi-structured interviews. All notes were transcribed, coded and analysed using a Grounded Theory approach to identify emerging themes. Results Paramedics expressed a wide range of frustrations with the scheme, identifying the waiting time, the process and a lack of confidence, experience and training as the three major barriers to referrals. They described how they approached patients with the GP referral scheme in mind, identified common characteristics of referrals, described how the triage tool shaped their decision making and shared how they involved the patient in the decision making. They shared too their frustrations with some GP decision making, which they admitted then influenced their future decision making. Finally, they described what motivated them to refer and discussed the lack of awareness and understanding of the scheme’s impact and aims. Conclusions This study provided valuable insight into the paramedic’s perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP’s perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success. https://emj.bmj.com/content/34/10/696.2 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2017-207114.4