Refugee experiences of general practice in countries of resettlement: a literature review

Background

Refugees and asylum seekers often struggle to use general practice services in resettlement countries.

Aim

To describe and analyse the literature on the experiences of refugees and asylum seekers using general practice services in countries of resettlement.

Design and setting

Literature review using systematic search and narrative data extraction and synthesis methodologies. International, peer-reviewed literature published in English language between 1990 and 2013.

Method

Embase, Ovid MEDLINE, PsycINFO, CSA Sociological Abstracts, and CINAHL databases were searched using the terms: refugee, asylum seeker, experience, perception, doctor, physician, and general practitioner. Titles, abstracts and full texts were reviewed and were critically appraised. Narrative themes describing the refugee or asylum seeker’s personal experiences of general practice services were identified, coded, and analysed.

Results

From 8722 papers, 85 were fully reviewed and 23 included. These represented the experiences of approximately 864 individuals using general practice services across 11 countries. Common narrative themes that emerged were: difficulties accessing general practice services, language barriers, poor doctor–patient relationships, and problems with the cultural acceptability of medical care.

Conclusion

The difficulties refugees and asylum seekers experience accessing and using general practice services could be addressed by providing practical support for patients to register, make appointments, and attend services, and through using interpreters. Clinicians should look beyond refugee stereotypes to focus on the needs and expectations of the individual. They should provide clear explanations about unfamiliar clinical processes and treatments while offering timely management.     

GPs' and pharmacists' experiences of managing multimorbidity: a ��Pandora's box��

Background

Multimorbidity is defined as the occurrence of two or more chronic diseases in one individual. Patients with multimorbidity generally have poorer health and functioning and higher rates of attendance in primary care and specialty settings.

Aim

To explore the views and attitudes of GPs and pharmacists managing patients with multimorbidity in primary care.

Design of study

Qualitative study using focus groups.

Setting

Primary care in Ireland.

Method

Three focus groups were held in total, involving 13 GPs and seven pharmacists. Focus groups were recorded, transcribed, and analysed using the ‘framework’ approach.

Results

The predominant themes to emerge from the focus groups were: 1) the concept of multimorbidity and the link to polypharmacy and ageing; 2) health systems issues relating to lack to time, inter-professional communication difficulties, and fragmentation of care; 3) individual issues from clinicians relating to professional roles, clinical uncertainty, and avoidance; 4) patient issues; and 5) potential management solutions.

Conclusion

This study provides information on the significant impact of multimorbidity from a professional perspective. It highlights potential elements of an intervention that could be designed and tested to achieve improvements in the management of multimorbidity, outcomes for individuals affected, and the experiences of those providing healthcare.     

Integrating preconception care for women with diabetes into primary care: a qualitative study

Background

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

Aim

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

Design of study

Qualitative, cross-sectional study.

Setting

A London teaching hospital and GP practices in the hospital catchment area.

Method

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

Results

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs'' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP''s role presents a challenge to implementing ‘shared’ preconception care.

Conclusion

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study''s findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.     

Quality care provision for older people: an interview study with patients and primary healthcare professionals

Background

In recent years, primary health care for the ageing population has become increasingly complex.

Aim

This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people.

Design and setting

This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands.

Method

All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached.

Results

Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals.

Conclusion

Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.     

Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral

Background

There is a large variation in referral rates to secondary care among GPs, which is partly unexplained.

Aim

To explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics.

Design and setting

A cross-sectional study in Northern Norway.

Method

Data were derived from 44 (42%) of 104 randomly selected GPs between 2008 and 2010. GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations on a four-level categorical scale. Associations were examined by multivariable ordered and multivariable multilevel logistic regression analyses.

Results

Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient. The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything. Female GPs referred to reassure the patient and due to perceived deficient medical knowledge significantly more often than male GPs. However, perceived easy accessibility of specialists was significantly less frequently given as a reason for referral by female GPs compared with male GPs. When the GPs scored the referrals to be of lesser medical necessity, male GPs referred significantly more frequently than female GPs to reassure the patient due to patient preference and perceived deficient medical knowledge.

Conclusion

There are striking differences in reasons for referral between Norwegian male and female GPs and between GPs with high and low referral rates, which reflects difficulties in handling professional uncertainty. Referring to reassure the patients, especially when referrals are less medically necessary, may reflect consideration and acquiescence towards the patients.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.     

Facilitators and barriers for GP�Cpatient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants

Background

Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care.

Aim

To obtain detailed information on facilitators and barriers for GP–patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills.

Design of study

Qualitative study with focus groups, interviews, and questionnaires.

Setting

GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands.

Method

GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers.

Results

Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors'' delay and strong demands from patients'' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor–patient relationships, while consultants report insufficient clarification of patients'' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios.

Conclusion

The study findings suggest that the quality of GP–patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated.     

GPs' awareness of patients' preference for place of death

Background

Being able to die in one''s place of choice is an indicator of the quality of end-of-life care. GPs may play a key role in exploring and honouring patients'' preferences for place of death.

Aim

To examine how often GPs are informed about patients'' preferred place of death, by whom and for which patients, and to study the expressed preferred place of death and how often patients die at their preferred place.

Design of study

One-year nationwide mortality retrospective study.

Setting

Sentinel Network of GPs in Belgium, 2006.

Method

GPs'' weekly registration of all deaths (patients aged ≥1 year).

Results

A total of 798 non-sudden deaths were reported. GPs were informed of patients'' preferred place of death in 46% of cases. GPs obtained this information directly from patients in 63%. GP awareness was positively associated with patients not being hospitalised in the last 3 months of life (odds ratio [OR] = 3.9; 95% confidence interval [CI] = 2.8 to 5.6), involvement of informal caregivers (OR = 3.3; 95% CI = 1.8 to 6.1), use of a multidisciplinary palliative care team (OR = 2.5; 95% CI = 1.8 to 3.5), and with presence of more than seven contacts between GP and patient or family in the last 3 months of life (OR = 3.0; 95% CI = 2.2 to 4.3). In instances where GPs were informed, more than half of patients (58%) preferred to die at home. Overall, 80% of patients died at their preferred place.

Conclusion

GPs are often unaware of their patients'' preference for place of death. However, if GPs are informed, patients often die at their preferred location. Several healthcare characteristics might contribute to this and to a higher level of GP awareness.     

Medical ethics in sub-Sahara Africa: closing the gaps

Background

Health care providers are expected to have the skills and knowledge relevant to their field and should also be familiar with the ethical and legal expectations that arise out of the standard practices.

Objectives

To elucidate the practice of the health care providers in relation to healthcare ethics in Nigeria.

Methods

A self-administered structured questionnaire was devised and distributed to staff of two tertiary health care facilities in Northern Nigeria. The questionnaire comprised of detailed questions regarding day-to-day aspects of Medical ethical issues.

Results

A total of 307(76.2%) out of 403 health care providers responded to the questionnaire. The median age of the respondents was 34 years. More than half 168(54.7%) of the respondents disagreed as to whether “Ethical conduct is important only to avoid legal action. Many respondents 135 (44.0%) agreed to adhering to “patient''s wishes”, on the other hand over two-third of the respondents 211 (68.7%) agreed that “doctor should do what is best” irrespective of the patient''s opinion. There were significant differences (p<0.05) between the perception of physicians and non-physicians on many ethical issues.

Conclusion

This study has shown gap in knowledge and practice of healthcare ethics among health care providers. There is a need for periodic education on clinical ethics in our hospitals.     

Experiences of front-line health professionals in the delivery of telehealth: a qualitative study

Background

Telehealth is an emerging field of clinical practice but current UK health policy has not taken account of the perceptions of front-line healthcare professionals expected to implement it.

Aim

To investigate telehealth care for people with long-term conditions from the perspective of the front-line health professional.

Design and setting

A qualitative study in three sites within the UK (Kent, Cornwall, and the London Borough of Newham) and embedded in the Whole Systems Demonstrator evaluation, a large cluster randomised controlled trial of telehealth and telecare for patients with long-term and complex conditions.

Method

Semi-structured qualitative interviews with 32 front-line health professionals (13 community matrons, 10 telehealth monitoring nurses and 9 GPs) involved in the delivery of telehealth. Data were analysed using a modified grounded theory approach.

Results

Mixed views were expressed by front-line professionals, which seem to reflect their levels of engagement. It was broadly welcomed by nursing staff as long as it supplemented rather than substituted their role in traditional patient care. GPs held mixed views; some gave a cautious welcome but most saw telehealth as increasing their work burden and potentially undermining their professional autonomy.

Conclusion

Health care professionals will need to develop a shared understanding of patient self-management through telehealth. This may require a renegotiation of their roles and responsibilities.     

GPs' attitudes, awareness, and practice regarding early diagnosis of dementia

Background

In primary care, the diagnosis of dementia is often delayed and the 2007 National Audit Office Report concluded action was needed to improve patient care and value for money.

Aim

To investigate the attitudes, awareness, and practice of GPs in England regarding early diagnosis and management of patients with dementia, and perceptions of local specialist services, to identify training or support needs.

Design of study

Secondary analysis of survey data that capture the above attitudes, awareness, and practice.

Setting

Online survey, targeting GP members of medeConnect.

Method

Survey data were obtained using an anonymised online self-completion questionnaire, and then analysed using standard data-analysis software.

Results

A total of 1011 GPs across the eight English regions responded. Older GPs were more confident in diagnosing and giving advice about dementia, but less likely to feel that early diagnosis was beneficial, and more likely to feel that patients with dementia can be a drain on resources with little positive outcome. Younger GPs were more positive and felt that much could be done to improve quality of life. Attitudes had no correlation with sex. GPs in general felt they had not had sufficient basic and post-qualifying training in dementia, and overall knowledge about dementia was low.

Conclusion

Much could be done to improve GPs'' knowledge of dementia, and the confidence of older GPs could be an educational resource. However, greater experience may create scepticism about early diagnosis because of the perceived poor quality of specialist services.     

GPs' views on the practice of physician-assisted suicide and their role in proposed UK legalisation: a qualitative study

Background

A bill to legalise assisted dying in the UK has been proposed in Parliament''s House of Lords three times since 2003. The House of Lords Select Committee concluded in 2005 that ‘the few attempts to understand the basis of doctors'' views have shown equivocal data varying over time’. Fresh research was recommended to gain a fuller understanding of health sector views.

Aim

To examine GPs'' views of the practice of physician-assisted suicide as defined by the 2005/2006 House of Lords (Joffe) Bill and views of their role in the proposed legislation; and to explore the influences determining GPs'' views on physician-assisted suicide.

Design of study

Qualitative interview study.

Setting

Primary care in South London, England.

Method

Semi-structured interviews with GPs were conducted by a lead interviewer and analysed in a search for themes, using the framework approach.

Results

Thirteen GPs were interviewed. GPs who had not personally witnessed terminal suffering that could justify assisted dying were against the legislation. Some GPs felt their personal religious views, which regarded assisted dying as morally wrong, could not be the basis of a generalisable medical ethic for others. GPs who had witnessed a person''s suffering that, in their opinion, justified physician-assisted suicide were in favour of legislative change. Some GPs felt a specialist referral pathway to provide assisted dying would help to ensure proper standards were met.

Conclusion

GPs'' views on physician-assisted suicide ranged from support to opposition, depending principally on their interpretation of their experience of patients'' suffering at the end of life. The goal to lessen suffering of the terminally ill, and apprehensions about patients being harmed, were common to both groups. Respect for autonomy and the right of self-determination versus the need to protect vulnerable people from the potential for harm from social coercion were the dominant themes.     

Prophylactic treatment of migraine by GPs: a qualitative study

Background

Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal.

Aim

To explore the opinions of GPs regarding preventive medication for migraine.

Design and setting

A qualitative focus group study in Dutch general practice.

Method

Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population.

Results

GPs perceived patients'' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs'' decisions were often based on considerations other than those presented in national guidelines, for example, the patient''s need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient.

Conclusion

Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines.     

Early identification of palliative care patients in general practice: development of RADboud indicators for PAlliative Care Needs (RADPAC)

Background

According to the World Health Organization (WHO) definition, palliative care should be initiated in an early phase and not be restricted to terminal care. In the literature, no validated tools predicting the optimal timing for initiating palliative care have been determined.

Aim

The aim of this study was to systematically develop a tool for GPs with which they can identify patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cancer respectively, who could benefit from proactive palliative care.

Design

A three-step procedure, including a literature review, focus group interviews with input from the multidisciplinary field of palliative healthcare professionals, and a modified Rand Delphi process with GPs.

Method

The three-step procedure was used to develop sets of indicators for the early identification of CHF, COPD, and cancer patients who could benefit from palliative care.

Results

Three comprehensive sets of indicators were developed to support GPs in identifying patients with CHF, COPD, and cancer in need of palliative care. For CHF, seven indicators were found: for example, frequent hospital admissions. For COPD, six indicators were found: such as, Karnofsky score ≤50%. For cancer, eight indicators were found: for example, worse prognosis of the primary tumour.

Conclusion

The RADboud indicators for PAlliative Care Needs (RADPAC) is the first tool developed from a combination of scientific evidence and practice experience that can help GPs in the identification of patients with CHF, COPD, or cancer, in need of palliative care. Applying the RADPAC facilitates the start of proactive palliative care and aims to improve the quality of palliative care in general practice.     

Economic influences on GPs' decisions to provide out-of-hours care

Background

Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work–life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs.

Aim

To analyse which factors influence an individual GP''s decision to re-provide OOH care when their practice has opted out.

Design of study

Cross-sectional questionnaire survey.

Setting

Rural and urban general practices in Scotland, UK.

Method

A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals'' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation.

Results

Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services.

Conclusion

The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.     

Unfashionable tales: narratives about what is (still) great in NHS general practice

Background

There is clear evidence that general practice has become a less popular career choice and among GPs there are high levels of dissatisfaction and demotivation. Little empirical evidence has emerged to indicate which factors contribute intrinsic value to the working lives of GPs and sustain their ongoing commitment.

Aim

To understand which aspects of work continue to motivate and engage senior GPs by exploring their narrative accounts.

Design and setting

This was part of a qualitative study in which senior GPs and hospital specialists contributed narratives in which they reflected on their working lives.

Method

Individual, open interviews were conducted with eight GPs who had graduated in the early 1980s. Thematic analysis and situational analysis mapping were used to identify and connect related themes.

Results

During interviews in which doctors drew on a wide range of encounters and experiences, they revealed which aspects of work were associated with greater intrinsic rewards and contributed to their continuing motivation. Having chosen careers that suited their preferred settings and working practices, they recounted adjustments made in response to new challenges and confirmed experiencing greater enjoyment when performing roles affirming their sense of providing valued health care.

Conclusion

This study’s findings offer an alternative angle from which to consider the current unpopularity of general practice careers. The article proposes that long-term engagement of practitioners may be achieved through provision of adequate supportive resources to allow them to enact a sense of medical identity that matches with their acquired expectations of their role in the NHS.     

Exploration of GPs' views and use of the fit note: a qualitative study in primary care

Background

Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work — the ‘fit note’ — was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews.

Aim

To explore GPs'' views and use of the fit note during its first year of operation.

Design and setting

Qualitative interview study of GPs based in different geographical locations across the UK.

Method

GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis.

Results

Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs'' operation of sickness certification. Feedback over the fit note''s impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed.

Conclusion

A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.     

Work-related sickness absence negotiations: GPs' qualitative perspectives

Background

GPs can find their role as issuers of sickness certification problematic, particularly in trying to maintain a balance between certifying absence and preserving the doctor–patient relationship. Little research has been published on consultations in which sickness absence has been certified.

Aim

To explore negotiations between GPs and patients in sickness absence certification, including how occupational health training may affect this process.

Method

A qualitative study was undertaken with GPs trained in occupational health who also participate in a UKwide surveillance scheme studying work-related ill-health. Telephone interviews were conducted with 31 GPs who had reported cases with associated sickness absence.

Results

Work-related sickness absence and patients'' requests for a ‘sick note’ vary by diagnosis. Some GPs felt their role as patient advocate was of utmost importance, and issue certificates on a patient’s request, whereas others offer more resistance through a greater understanding of issues surrounding work and health aquired through occupational health training. GPs felt that their training helped them to challenge beliefs about absence from work being beneficial to patients experiencing ill-health; they felt better equipped to consider patients’ fitness for work, and issued fewer certificates as a result of this.

Conclusion

Complex issues surround GPs'' role in the sickness-certification process, particularly when determining the patient''s ability to work while maintaining a healthy doctor–patient relationship. This study demonstrates the potential impact of occupational health training for GPs, particularly in light of changes to the medical statement introduced in 2010.