1. Delivering High Quality Care for Older People History taking
Robbie Foy
October 2017

2. Those who cannot remember the past are condemned to repeat it.
George Santayana

3. History is just one ****ing thing after another.
The History Boys
Alan Bennett

4. History taking

6. Ethnographic observations of depression screening
Nurse: Are you alright, you haven’t been having little interest in doing things, or? Patient: No, no. Nurse: Are you fine, are you okay? That’s okay. Patient: It’s been 10 years since I’ve lost [wife]. Nurse: Is it, what, is that your wife? Patient: Yes. Nurse: 10 years? That’s a long time, isn’t it. Can I just check your tablets then, do you take aspirin, bendrofluazide…
Alderson et al. Incentivised case finding for depression in patients with chronic heart disease and diabetes in primary care: an ethnographic study. BMJ Open 2014;4:e005146

7. What’s the context? Multiple top-down priorities
Multiple bottom-up priorities
2.5 problems per 11.9 minutes
Multi-morbidities
23% primary care patients
82% aged 85 years or over
Multiplying demand
Multiple ‘re-disorganisation’
Salisbury BJGP 2013; DOI: /bjgp13X674431
Barnett et al. Lancet 2012;380:37-43
Baird et al. King’s Fund 2016

8. Obey The Bouncer Rule…

10. Mean scores for clinical quality at practice level for coronary heart disease, asthma, and type 2 diabetes, 1998 to Reproduced with permission from Campbell et al. N Engl J Med 2007;357:
Brown, C. et al. BMJ 2008;337:a2764
Copyright ©2008 BMJ Publishing Group Ltd.

11. Mean scores for clinical quality at practice level for coronary heart disease, asthma, and type 2 diabetes, 1998 to Reproduced with permission from Campbell et al. N Engl J Med 2007;357:
Brown, C. et al. BMJ 2008;337:a2764
Copyright ©2008 BMJ Publishing Group Ltd.

12. A ‘real world’ trial Adapted implementation package 40 practices
Diabetes
Intervention
Control
Risky prescribing
Adapted implementation package
32 practices
Blood pressure control
Intervention
Control
Anticoagulation in
atrial fibrillation
Willis et al. Implementation Science 2016;11:25

13. Control 6.0% Intervention 4.9% Odds ratio 0.81 (97.5% CI 0.67 to 0.99)
Risky prescribing
Control %
Intervention 4.9%
Odds ratio 0.81 (97.5% CI 0.67 to 0.99)
Once confounders adjusted for, the odds of a patient achieving outcome in intervention practices was 18.5% lower compared with a patient with same characteristics in control practices

14. Not at all Two-fold Five-fold Ten-fold
How much do general practices vary in initiating prescribing of strong opioids?
Not at all Two-fold Five-fold Ten-fold
Foy et al. Prescribed opioids in primary care: cross sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016

15. Not at all Two-fold Five-fold Ten-fold
How much do general practices vary in initiating prescribing of strong opioids?
Not at all Two-fold Five-fold Ten-fold
Foy et al. Prescribed opioids in primary care: cross sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016

16. Prescribing of opioids for chronic, non-cancer pain in general practice
Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, Carder P, Faulkner S, Glidewell L, West R. Prescribed opioids in primary care: cross sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016;6:e

17. Prescribing of opioids for chronic, non-cancer pain in general practice
Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, Carder P, Faulkner S, Glidewell L, West R. Prescribed opioids in primary care: cross sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016;6:e

18. History taking
Think twice in the rush for innovation
Embrace opportunities for rigorous evaluation… and how to build such research into service evolution
Consider how to attach eFI to small changes at a patient level that can make a big difference at a population level

19. Acknowledgements
This presentation summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Grant Reference Numbers RP-PG ) and Research for Patient Benefit Programme (RP-PG and RP-PG )
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health