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General practitioners and other primary care professionals have a leading role in contemporary health care, which Trisha Greenhalgh explores in this highly praised new text. She provides perceptive and engaging insights into primary health care, focussing on: its intellectual roots its impact on the individual, the family and the community the role of the multidisciplinary team contemporary topics such as homelessness, ethnic health and electronic records. Concise summaries, highlighted boxes, extensive referencing and a dedicated section on effective learning make this essential reading for postgraduate students, tutors and researchers in primary care. ___ From the foreword by Julian Tudor Hart "Trish Greenhalgh, in her frequent columns in the British Medical Journal…more than any other medical journalist spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science. When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947-52, the advance is stunning." ___ "Trish Greenhalgh is one of the international stars of general practice and a very clever thinker. This new book is a wonderful resource for primary health care and general practice. Every general practice registrar should read this book and so should every general practice teacher and primary care researcher." Professor Michael Kidd, Head of the Department of General Practice, University of Sydney and Immediate Past President of The Royal Australian College of General Practitioners "This important new book by one of primary care's most accomplished authors sets out clearly the academic basis for

Das Schlagwort von einer "Evidence-based Medicine" (EBM) macht seit einiger Zeit die Runde. Entscheidende Grundlage für die Anwendung von EBM ist es, Veröffentlichungen "richtig" lesen zu können. Trisha Greenhalgh erklärt in ihrem Buch leicht verständlich, wie medizinische Artikel gelesen werden und was sonst noch dazu gehört, um eine evidenzbasierte Medizin zu betreiben. Sie zeigt, wie man gezielt die richtigen Fachartikel findet, um Fragen aus der Praxis und für die Forschung beantworten zu können. Dabei macht sie die Unterschiede zwischen den Formen der wissenschaftlichen Publikationen deutlich, erklärt, wie man Artikel kritisch beurteilt und für den individuellen Fall nutzbar macht. Mit konkreten Fragen, Checklisten und Beispielen aus der Praxis gibt sie dem Leser eine Methodik an die Hand, mit der er sich im medizinischen Informationsdschungel zurechtfinden und sein Wissen für die alltägliche Arbeit und zum Wohle der Patienten anwenden kann.

POLICY POINTS: For complex reasons, the promise of "precision medicine" based on molecular pathways remains unrealized for many conditions. Clinical practice guidelines (theoretically, at least) can act as "trailblazers" to introduce tests and treatments that reflect precision medicine discoveries. We describe a detailed case study from the United Kingdom in which such an attempt was (so far) unsuccessful and show how this case provides generalizable lessons. Policymakers should be wary of using clinical practice guidelines as the sole, or even the primary, lever for introducing precision medicine. CONTEXT: Precision medicine, which addresses underlying molecular mechanisms of disease, depends on new technologies that measure specific biomarkers, leading (it is anticipated) to more accurate diagnosis, patient stratification, and tailored treatment. These technologies can be disruptive—that is, they make possible, and often require, radical changes to clinical practice and service organization—thereby improving quality, safety, or efficiency of care. Clinical practice guidelines may act as "trailblazers," introducing and legitimizing novel technologies and practices. METHODS: We describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker (fractional exhaled nitric oxide, FeNO), measured using a portable breath device. We collected a wide‐ranging data set that included more than 100 documents, 61 interviews, and 150 hours of ethnographic observation, and we analyzed it using technology‐enhanced strong structuration theory (TESST). FINDINGS: Our study describes a so‐far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government‐endorsed national guideline. These researchers considered asthma management, especially in primary care, to be characterized by overdiagnosis and poor tailoring of treatment; engaged a national guideline ...

Abstract Background Self-management is rarely studied 'in the wild'. We sought to produce a richer understanding of how people live with diabetes and why self-management is challenging for some. Method Ethnographic study supplemented with background documents on social context. We studied a socio-economically and ethnically diverse UK population. We sampled 30 people with diabetes (15 type 1, 15 type 2) by snowballing from patient groups, community contacts and NHS clinics. Participants (aged 5-88, from a range of ethnic and socio-economic groups) were shadowed at home and in the community for 2-4 periods of several hours (total 88 visits, 230 hours); interviewed (sometimes with a family member or carer) about their self-management efforts and support needs; and taken out for a meal. Detailed field notes were made and annotated. Data analysis was informed by structuration theory, which assumes that individuals' actions and choices depend on their dispositions and capabilities, which in turn are shaped and constrained (though not entirely determined) by wider social structures. Results Self-management comprised both practical and cognitive tasks (e.g. self-monitoring, menu planning, medication adjustment) and socio-emotional ones (e.g. coping with illness, managing relatives' input, negotiating access to services or resources). Self-management was hard work, and was enabled or constrained by economic, material and socio-cultural conditions within the family, workplace and community. Some people managed their diabetes skilfully and flexibly, drawing on personal capabilities, family and social networks and the healthcare system. For others, capacity to self-manage (including overcoming economic and socio-cultural constraints) was limited by co-morbidity, cognitive ability, psychological factors (e.g. under-confidence, denial) and social capital. The consequences of self-management efforts strongly influenced people's capacity and motivation to continue them. Conclusion Self-management of diabetes is physically, intellectually, emotionally and socially demanding. Non-engagement with self-management may make sense in the context of low personal resources (e.g. health literacy, resilience) and overwhelming personal, family and social circumstances. Success of self-management as a policy solution will be affected by interacting influences at three levels: [a] at micro level by individuals' dispositions and capabilities; [b] at meso level by roles, relationships and material conditions within the family and in the workplace, school and healthcare organisation; and [c] at macro level by prevailing economic conditions, cultural norms and expectations, and the underpinning logic of the healthcare system. We propose that the research agenda on living with diabetes be extended and the political economy of self-management systematically studied.

Few interventions that succeed in improving healthcare locally end up becoming spread and sustained more widely. This indicates that we need to think differently about spreading improvements in practice. Drawing on a focused review of academic and grey literature, the authors outline how spread, scale-up, and sustainability have been defined and operationalised, highlighting areas of ambiguity and contention. Following an overview of relevant frameworks and models, they focus on three specific approaches and unpack their theoretical assumptions and practical implications: the Dynamic Sustainability Framework, the 3S (structure, strategy, supports) infrastructure approach for scale-up, and the NASSS (non-adoption, abandonment, and challenges to scale-up, spread, and sustainability) framework. Key points are illustrated through empirical case narratives and the Element concludes with actionable learning for those engaged in improvement activities and for researchers. This title is also available as Open Access on Cambridge Core.

Dieses Buch ist die einzige deutschsprachige Anleitung, wie wir "sprechende Medizin" lernen und anwenden können. Verschiedene Krankheitsgeschichten werden von Patienten und ihren Ärzten sensibel geschildert. Schließlich schlägt das Buch Brücken zu verschiedenen anderen Disziplinen, die alle Interessantes und Wichtiges über medizinische Praxis, Forschung und Ausbildung zu sagen haben, und eröffnet den Blick auf die Bedeutung der Narration im gesamten Gesundheitswesen.

During crises (major events characterised by uncertainty, urgency and threat), society must make sense of rapidly unfolding events. This happens mainly through narrativising—depicting a setting, characters and a meaningful sequence of events and actions unfolding over time. In the early months of the pandemic, UK general practice shifted from face-to-face consultations to a remote-by-default model (telephone, video or e-consultation). This shift was initially widely accepted by press and public, but support waned after a politician declared that the change would be permanent. We invoke Burke's dramatistic pentad of act, scene, agent, agency and purpose to theorise findings from a detailed analysis of media coverage of the remote-by-default policy and reactions to it. We consider the 12 weeks from March to June 2020 (first lockdown, when remote-by-default services had just been introduced) and 1 week from late July 2020 (following the ministerial announcement). The initial introduction of remote consulting had strong narrative coherence in which all parts of the pentad were balanced: scene (a deadly virus threatening the country) aligned with act (lockdown, including avoiding face-to-face appointments unless essential), agents (the National Health Service and digital technology as heroic macro-actors), agency (general practitioners 'deployed') and purpose (to control the pandemic). The later period, however, was characterised by a mismatch between scene (a country emerging from lockdown and resuming normal life), act (imposition of the remote model), agent (a politician known for his enthusiasm for technology), agency (top-down directive) and purpose (modernisation). Whereas media narratives in the first period aligned with the genre of heroic adventure (suggesting a worthy battle, bravely fought), those of the second had characteristics of farce (something both comic and grotesque). We conclude that close reading of media narratives may surface potential misalignments between policy decisions and the context in ...

AbstractWith the reflexive turn in the social sciences, emotional engagement is an inevitable and crucial part of data‐gathering and analysis. However, there is a glaring gap in methodological discussions to this end. Presenting ethnographic research into end of life with people living at home in England with heart failure, we argue for a methodological blend of engagement and detachment that shifts throughout the research process, and that sensory experience is a core part of engagement. We offer ethnographic examples which present and explore some alternatives to emotional engagement and objective detachment: (1) moving with participants to facilitate engagement during fieldwork through shared sensory experience; (2) detachment as a different way of relating when exiting the field and drawing participant relationships to a close; and (3) ethnographic closeness as the interplay of engagement and detachment in participant debriefing and data analysis. Based on well‐established anthropological concepts, and taking both engagement and detachment as embodied and relational, we develop a notion of ethnographic closeness in which detachment is a necessary part. Our detailed methodological discussion thus offers theoretically grounded possibilities and alternatives for approaching and managing the core tension of 'how close is too close?' in ethnographic practice. Further contributions supporting researchers in navigating ethnographic research are needed.

BACKGROUND: Remote consulting was introduced quickly into UK general practice in March 2020 as an emergency response to COVID-19. In July 2020, 'remote-first' became long-term government policy. AIM: To explore how this change was portrayed in national newspapers and how depictions changed over time. DESIGN AND SETTING: Thematic analysis of newspaper articles referring to remote GP consultations from two time periods: 2 March–31 May 2020 (period 1) and 30 July–12 August 2020 (period 2). METHOD: Articles were identified through, and extracted from, LexisNexis Academic UK. A coding system of themes and narrative devices was developed and applied to the data. The analysis was developed iteratively, amending the coding structure as new data were added. RESULTS: Remote consulting was widely covered in newspapers. Articles in period 1 depicted it positively, equating digital change with progress and linking novel technological solutions with improved efficiency and safety (for example, infection control) in a service that was overdue for modernisation. Articles in period 2 questioned the persistence of a remote-first service now that the pandemic was waning, emphasising, for example, missed diagnoses, challenges to the therapeutic relationship, and digital inequalities. CONCLUSION: As the first wave of the pandemic came and went, media depictions of remote consulting evolved from an 'efficiency and safety' narrative to a 'risks, inequalities, and lack of choice' narrative. To restore public trust in general practice, public communication should emphasise the wide menu of consulting options now available to patients and measures being taken to assure safety and avoid inequity.

Policies and programmes that tackle neighbourhood deprivation have long been a feature of urban policy in the UK and elsewhere. Large-scale urban regeneration and neighbourhood renewal programmes have been deployed as the primary vehicle to improve the health and life chances of residents of deprived neighbourhoods. Often these areas have a long history of efforts at regeneration and redevelopment and, over time, have become labelled as 'problem areas' in need of constant intervention. The bid for the London 2012 Olympic and Paralympic Games was successful partly due to its promise to deliver a lasting health and social legacy by using the Games as a driver of regeneration in East London. Despite limited evidence for the effectiveness of such an approach, regeneration schemes tied to sporting events have emerged as popular strategies through which cities strive to enhance their urban fabric. Running through the core of the London 2012 bid was a discourse of East London as a 'problem' in need of a regeneration 'solution' that the Olympics uniquely could deliver. As a result, a wider narrative of East London was generated: as unhealthy; mired in poverty; desperate for jobs; with an inadequate and outdated built environment. The Olympic legacy was thus positioned as a unique once-in-a-lifetime solution 'accelerating' regeneration in East London, and delivering substantive change that either might not have happened, or would otherwise have taken decades. Through documentary analysis of published Government policy documents for the period 2002-2011, we demonstrate how the 'problem' of East London was used as political justification for London 2012. We argue that the Olympic legacy was deliberately positioned in neoliberal terms in order to justify substantial economic investment by the UK government and suit the needs of the International Olympic Committee. Finally, whilst acknowledging that regeneration may indeed result, we also speculate on the potential legacy and possible challenges for the people in East London left by this neoliberal and entrepreneurial strategy.