Citizens' expectations and likely use of a NHS Walk-in Centre: results of a survey and qualitative methods of research

Objectives  To find out which groups of people would use a National Health Service walk-in centre that would offer mainly health care advice, staffed by nurses. To understand the circumstances in which people would use a walk-in centre and to ascertain to what extent it would meet patients' expressed health-care needs.
Design  A postal survey of 2400 people plus 27 semi-structured interviews and one focus group.
Setting and participants  The study was conducted in Wakefield, Yorkshire UK, and included both white and ethnic minority groups.
Results  Most people reported that they would use a walk-in centre. It would be more attractive to young as compared with older people, ethnic minority as compared with white people, people who are dissatisfied with access to NHS services and people with urgent health-care problems. People want a wide range of services, including diagnosis, treatment, prevention, and general information. People also want access to both doctors and nurses, to male as well as female practitioners, to counsellors and interpreters. The type of service planned for this walk-in centre will meet some of the expressed needs. However, patients' expectations of the walk-in centre exceed planned provision in a number of key respects.
Conclusion  Walk-in centres without GPs and with limited services will disappoint the public. It is important that walk-in centres are evaluated and attention paid to 'local voices' before additional money is allocated for such centres elsewhere.     

Patients' perceptions and experiences of transitions in diabetes care: a longitudinal qualitative study

Objective  To examine patients' perceptions and experiences over time of the devolvement of diabetes care/reviews from secondary to primary health-care settings.
Design  Repeat in-depth interviews with 20 patients over 4 years.
Participants and setting  Twenty type 2 diabetes patients recruited from primary- and secondary-care settings across Lothian, Scotland.
Results  Patients' views about their current diabetes care were informed by their previous service contact. The devolvement of diabetes care/reviews to general practice was presented as a 'mixed blessing'. Patients gained reassurance from their perception that receiving practice-based care/reviews signified that their diabetes was well-controlled. However, they also expressed resentment that, by achieving good control, they received what they saw as inferior care and/or less-frequent reviews to others with poorer control. While patients tended to regard GPs as having adequate expertise to conduct their practice-based reviews, they were more ambivalent about nurses taking on this role. Opportunities to receive holistic care in general practice were not always realized due to patients seeing health-care professionals for diabetes management to whom they would not normally present for other health issues.
Conclusions  It is important to educate patients about their care pathways, and to reassure them that frequency of reviews depends more on clinical need than location of care and that similar care guidelines are followed in hospital clinics and general practice. A patients' history of service contact may need to be taken into account in future studies of service satisfaction.     

Defining information need in health – assimilating complex theories derived from information science

Background Key policy drivers worldwide include optimizing patients’ roles in managing their care; focusing services around patients’ needs and preferences; and providing information to support patients’ contributions and choices. The term information need penetrates many policy documents. Information need is espoused as the foundation from which to develop patient‐centred or patient‐led services. Yet there is no clear definition as to what the term means or how patients’ information needs inform and shape information provision and patient care. Theoretical synthesis The assimilation of complex theories originating from information science has much to offer considerations of patient information need within the context of health care. Health‐related research often focuses on the content of information patients prefer, not why they need information. This paper extends and applies knowledge of information behaviour to considerations of information need in health, exposing a working definition for patient information need that reiterates the importance of considering the patient’s goals and understanding the patient’s context/situation. A patient information need is defined as ‘recognition that their knowledge is inadequate to satisfy a goal, within the context/situation that they find themselves at a specific point in the time’. This typifies the key concepts of national/international health policy, the centrality and importance of the patient. Conclusions The proposed definition of patient information need provides a conceptual framework to guide health‐care practitioners on what to consider and why when meeting the information needs of patients in practice. This creates a solid foundation from which to inform future research.     

Conversation analysis: a method for research into interactions between patients and health-care professionals

Background  It is clear that much of the success of health-care provision depends on the quality of interactions between health professionals and patients. For instance, it is widely recognized that patients are more likely to take medication effectively if they have been involved in discussions about treatment options, and understand and support the decision about what is prescribed (patient concordance). Hence, patient participation is important for the success of medical outcomes. The key is to explore how communicative choices made by health professionals impact on the quality of interactions in general, and of patient participation in particular. However, to date there has not been an appropriate method for investigating this connection or impact.
Objective  To outline the perspective and method of Conversation Analysis (CA). Developed within sociology and linguistics, CA offers a rigorous method (applicable to large data sets) to the study of interaction in health settings.
Strategy  The method of CA is illustrated through a review of CA studies of doctor–patient interactions. Two such studies, one from the US and the other from Finland, are reviewed, in order to show how CA can be applied to identifying both forms of patient participation, and the interactional conditions which provide opportunities for patient participation. These studies focus principally on the medical examination and diagnostic stages of the consultation. Further research will examine the forms and conditions of patient participation in decision-making.     

Health-care technology assessment: a clinical perspective

Health technology assessment needs to relate to contemporary questions which concern public health-care systems: how to keep people healthy, how to focus on the needs of those with chronic disabilities and integrate care between the hospital and the community, how to encourage and audit effective teamwork, and how to establish a consensus about what is effective and affordable. Clinicians have an ethical responsibility to practice efficiently and economically, for profligacy in the care of one patient may mean that another is treated inadequately. For similar reasons, clinicians need to play a full role in the management of services. Advice from health technology assessment is vital and needs to be accurate, relevant, timely, clear, and accessible. As well as being concerned about what works, we need also to eliminate from practice what does not. Regular audit and appraisal of practice against the evidence base should be useful in this respect. Alternative approaches to management, such as the provision of care as opposed to aggressive treatments, need to be evaluated, and health technology assessment needs to consider how services are delivered, not just specific treatments.     

Management of mental disorders in rural primary care: a proposal for integrated psychosocial services

Mental health facilities and specialized providers are particularly lacking in rural areas. Even when these are available, poverty, negative attitudes toward mental health treatments, and traditional rural values of privacy and autonomy often result in low utilization rates. Consequently, most mental health care in rural America is provided by primary care physicians who are also faced with competing demands, including tensions among limited time and resources, the multiple and complex needs of patients, and economic forces determining reimbursements. We propose that in the best interest of physicians and their patients, fully integrated psychosocial services in rural primary care settings would reduce the burden of time-consuming mental health care, conform to patient preference for immediate on-site care, reduce nonproductive medical care use, and eliminate duplication of effort by physicians and mental health professionals. The treatment model we propose would provide multiple arenas for psychosocial intervention - with the individual, the family, and the community - based on the patient's self-identified needs. The integration of psychosocial services within primary rural care is readily available, economically feasible, and urgently needed, but physicians must take the lead to implement this collaborative treatment partnership.     

Delayed Care and Unmet Needs among Health Care System Users: When Does Fiduciary Trust in a Physician Matter?

Objectives. To examine whether fiduciary trust in a physician is related to unmet health care needs and delayed care among patients who have a regular physician, and to investigate whether the relationships between trust and unmet health care needs and delays in care are attenuated for disadvantaged patients who face structural obstacles to obtaining health care.
Data Sources/Study Setting. The 1998–1999 Community Tracking Study (CTS) Household Survey, a cross-sectional sample representative of the U.S. noninstitutionalized population. This study analyzes adults who usually see the same physician for their health care ( n =29,994).
Study Design. We estimated logistic regression models of the association of trust with unmet health care needs and delayed care. We tested interactions between trust and barriers to obtaining care, including minority race/ethnicity, poverty, and the absence of health insurance. Control variables included patients' sociodemographic characteristics, health status, satisfaction with the available choice of primary physicians, and the number of physician visits during the last year.
Principal Findings. Patients' fiduciary trust in a physician is negatively associated with the likelihood of reporting delayed care and unmet health care needs among most patients. Among African Americans, Hispanics, the poor, and the uninsured, however, fiduciary trust is not significantly associated with the likelihood of delayed care. For unmet needs, only the uninsured have no significant association with trust.
Conclusions. Results show that trust is associated with improved chances of getting needed care across most subgroups of the population, although this relationship varies by subpopulation.     

Does NHS Direct empower patients?

NHS Direct is a 24h telephone helpline established in England and Wales, UK to offer advice and information for people about health, illness and the National Health Service (NHS) so that they are better able to care for themselves and their families. In 2001/2002 we undertook in-depth home interviews with 60 users of the service in two NHS Direct sites in England. In this paper we consider the extent to which NHS Direct facilitates patient empowerment in terms of helping people to be in control of their health and health care interactions. Our research suggests that NHS Direct facilitates patient empowerment by enabling patients to self care and to access health advice and services. It is also seen to offer the prerequisites for empowerment perceived to be lacking in the wider NHS, including time, respect, listening, support, and information. The service also functions by offering an alternative contact point for people seeking to avoid being labelled 'time wasters' by other busy health care providers. In the context of a wider health service which appears to problematise individuals' ability to make decisions about the appropriateness of seeking health care, NHS Direct legitimises help-seeking actions. Empowerment in the context of NHS Direct has been associated with self care as a way of reducing 'unnecessary' demand on health services. However, health professional and patient perspectives on what is considered necessary demand differ, and in certain contexts, patient empowerment may involve service use as well as self care. Further, our data reveal the context-dependent nature of a concept like empowerment. For example, when people are ill, in pain, or anxious about a loved one, they may value being cared for more than being empowered. Our research suggests that, in addition to its other functions, NHS Direct is also valued as contributing to a sense of being cared for.     

How does satisfaction with the health-care system relate to patient experience?

Objective

To explore what determines people’s satisfaction with the health-care system above and beyond their experience as patients.

Methods

Data on health system responsiveness, which refers to the manner and environment in which people are treated when they seek health care, provide a unique opportunity to better understand the determinants of people’s satisfaction with the health-care system and how strongly this is influenced by an individual’s experience as a patient. The data were obtained from 21 European Union countries in the World Health Survey for 2003. Additive ordinary least-squares regression models were used to assess the extent to which variables commonly associated with satisfaction with the health-care system, as recorded in the literature, explain the variation around the concept of satisfaction. A residual analysis was used to identify other predictors of satisfaction with the health-care system.

Findings

Patient experience was significantly associated with satisfaction with the health-care system and explained 10.4% of the variation around the concept of satisfaction. Other factors such as patient expectations, health status, type of care, and immunization coverage were also significant predictors of health system satisfaction; although together they explained only 17.5% of the observed variation, while broader societal factors may largely account for the unexplained portion of satisfaction with the health-care system.

Conclusion

Contrary to published reports, people’s satisfaction with the health-care system depends more on factors external to the health system than on the experience of care as a patient. Thus, measuring the latter may be of limited use as a basis for quality improvement and health system reform.     

Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership

Background  

To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery.     

Justice and Proximity: Problems for an Ethics of Care

This paper aims at addressing some questions considering the conflicting normative claims of partiality, i.e. to provide for the caring needs of the particular patient, and impartial claims of treating all patients with a relevant need equally. This ethical conflict between different conceptions of moral responsibilities within professional ethics relates to debates between an ethics of care and an ethics of justice. An ethics of care is a particularistic position that endorses some form of partiality, i.e. favouring persons to whom one stands in particular relationships. This paper argues that also a professional ethics must endorse some kind of partiality at the clinical level of health care. In fact, consideration of care for particular patients is a prerequisite for giving proper and attentive care towards the individual patient. This paper will discuss how partial concerns might be balanced against claims of distributive justice within the frame of the formal principle of justice. It is concluded that there is an urgent need for the recognition of the consequences of macro-level decisions for the possibility of the discharge of moral responsibility on a clinical level of health care. This would mean that health care institutions should adapt for the possibility of a basic standard of proper care and attention for the individual patient.     

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.     

Patients' perceptions of discrimination during hospitalization

Objective  To identify sources of perceived discrimination during hospitalization and examine the relationship of perceived discrimination to patient and hospital stay characteristics, and to patient ratings of care.
Background  Patient experiences of discrimination within the health-care system are associated with delays in care seeking, non-adherence to medical advice and poorer health status. Most research to date has focused on race and ethnicity-based discrimination, and few studies have included hospitalized patients.
Methods  Questions about patients' experiences of discrimination were added to a regular patient opinion survey conducted at the Geneva University Hospitals. Participants were 1537 adult residents of Switzerland discharged from the hospital between 15 February and 15 March 2007.
Results  A total of 171 (11.1%) respondents reported at least one source of discrimination. Most (93, 54.4%) reported a single cause of discrimination. The most frequent causes of discrimination were language, age, nationality and having a disease that is viewed negatively by others. Fifteen percentage of non-European respondents reported at least one of the following types of discrimination: language, nationality, religion and skin colour. Reporting discrimination from any cause was associated with higher Picker Patient Experience problem scores, and patients who reported discrimination were less likely to describe their care as very good or excellent and less likely to recommend the hospital to others.
Conclusions  Patient experiences of discrimination during hospitalization are relatively frequent and are associated with lower patient ratings of care. Collection of data on patient experiences of discrimination may contribute to the development of interventions aimed at ensuring respectful, quality care for all patients.     

Faculty development: a ‘Field of Dreams’?

Objectives  Participants in faculty development workshops often comment that 'those who need faculty development the most attend the least'. The goals of this study were to explore the reasons why some clinical teachers do not participate in centralised faculty development activities and to learn how we can make faculty development programmes more relevant to teachers' needs.
Methods  In 2006, we conducted focus groups with 16 clinical teachers, who had not participated in faculty development activities, to ascertain their perceptions of faculty development, reasons for non-participation and perceived barriers to involvement. Content analysis and team consensus guided the data interpretation.
Results  Focus group participants were aware of faculty development offerings and valued the goals of these activities. Important reasons for non-participation emerged: clinical reality, which included volume of work and lack of (protected) time; logistical issues, such as timing and the central location of organised activities; a perceived lack of financial reward and recognition for teaching, and a perceived lack of direction from, and connection to, the university.
Conclusions  Clinical reality and logistical issues appeared to be greater deterrents to participation than faculty development goals, content or strategies. Moreover, when asked to discuss faculty development, teachers referred to their development as faculty members in the broadest sense, which included personal and career development. They also expressed the desire for clear guidance from the university, financial rewards and recognition for teaching, and a sense of 'belonging'. Faculty development programmes should try to address these organisational issues as well as teachers' personal and professional needs.     

Misdirections in the professional training used to prepare psychologists in Brazil to work in the public health-care system]

In Brazil, the practice of psychologists in public health-care institutions is hampered by the professional training that they have received. That training is inadequate in meeting the requirements of primary health care, in satisfying the needs of the patients who use the public health-care system, and in overcoming the social inequalities that exist in Brazil. This piece is intended to identify the factors that make it harder to provide adequate psychological care in public health-care institutions, especially in the local Basic Health Units of Brazil's public health-care system, the Unified Health System. These hindrances to providing good care mainly originate in training that points psychologists in the direction of very restricted models of health care. These narrow models prevent the psychologists from responding appropriately to the needs of their patient clientele and of the public institutions. These limited models also make it hard for psychologists to adapt to the dynamic conditions that they will face in the Unified Health System.     

Exploring kidney patients' experiences of receiving individual peer support

Background  Peer support schemes of various types are commonly offered to patients as an adjunct to health and social care services provided by professionals. For patients with chronic illness, peer support interventions have recently become associated with more directive attempts to increase self management and improve healthcare outcomes. There is little qualitative research on patients' experiences of one-to-one peer support.
Purpose  To explore kidney patients' experiences of receiving individual peer support.
Setting  Two large teaching hospital renal units in South London, with peer support services for patients on the pre-dialysis care pathway.
Methods  Qualitative telephone interviews with a purposive, maximum variation sample of 20 people who had received peer support.
Results  The majority of respondents were overwhelmingly positive about their experience of peer support and its benefits. They valued peer support because it had given them access to practical information about kidney disease, based on lived experience, which helped them reach decisions about treatment. Peer supporters offered patients empathy and understanding; confirmation that they were not alone in suffering; positive role models of coping with treatment for kidney disease; and hope for the future. Peer support helped patients adapt to chronic illness by normalizing adherence to demanding treatment regimes and increasing patients' sense of empowerment and agency.
Conclusions  A brief meeting with a peer supporter delivered similar perceived benefits to those described by participants in support groups. Possible explanations for this include selection and training of peer supporters; careful matching of patients with peer supporters; and responsiveness to individual user-defined needs for information and psychosocial support.