BackgroundDecisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As 'gatekeepers' to NHS, GPs are expected to make best use of resources and may be criticised for 'inappropriate' admissions. Little is understood about the influences on GPs as they make such decisions AimTo explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital. Design and settingA purposive sample of 21 GPs from two counties in the South of England. MethodData from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method. ResultsThis study suggests that while clinical assessment, perceived benefits and risks of admission, and patients' and relatives' preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable. ConclusionDeveloping a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.

This group of nurses were aware of the difficulties of working in a hierarchical, profit-making culture. Individually, they tried to provide good quality care for patients and aspired to teamworking, but seldom succeeded to their satisfaction. There may be considerable potential to improve the working lives of staff and quality of patient care by effective teamworking. However, significant barriers, particularly concerning organizational culture, need to be overcome.

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To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not increase the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (< 10%) read or took health promotion leaflets. These results suggest that the role of waiting room notice-boards should be reassessed. More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation.

Irrigating ears to remove wax is a time-consuming procedure in UK primary care. In many other countries bulb syringes are used for self-clearance of earwax but evidence of their effectiveness is lacking. AimTo compare the effectiveness of self-treatment bulb syringes with routine care. Design of studyOpen, randomised, controlled trial. SettingSeven practices in Hampshire, UK. MethodParticipants were 237 patients attending their GP or practice nurse with symptomatic occluding earwax. A further 128 patients did not want to be part of the randomisation but allowed their data to be analysed. Patients randomised to intervention (n = 118) were given ear drops, a bulb syringe, and instructions on its use. Patients in the control group (n = 119) received ear drops, followed by ear irrigation by the GP or practice nurse. Main outcome measures were symptoms (on a 7-point scale), wax clearance, need for further treatment, and the acceptability of treatment. ResultsComparing patients using the bulb syringe with those treated with conventional irrigation, the change in mean symptom score was Ã0.81 and Ã1.26 respectively (difference Ã0.45, 95% confidence interval [CI] = Ã0.11 to Ã0.79) and, regarding the proportion requiring no further irrigation, 51% and 69% respectively. Although irrigation was preferred by more patients, most patients using the bulb syringe would use it again (75% versus 100%) and were satisfied with treatment (71% versus 99%). ConclusionsAdvising patients with ears blocked by wax to try bulb syringing before irrigation is effective and acceptable, and could significantly reduce the use of NHS resources.