The ‘added value’ GPs bring to commissioning: a qualitative study in primary care

Background

The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.

Aim

To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.

Design and setting

In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.

Method

A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.

Results

Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.

Conclusion

GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration.     

GPs’ views on managing advanced chronic kidney disease in primary care: a qualitative study

BackgroundChronic kidney disease (CKD) has become a significant part of the GP’s workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology.AimTo explore GPs’ views of managing patients with advanced CKD and referral to secondary care.MethodSemi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed.ResultsGPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient’s interests.ConclusionGPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams.     

Diagnosing dementia in Dutch general practice: a qualitative study of GPs’ practices and views

BackgroundGPs play an important role in recognising the symptoms of dementia; however, little is known about how they perceive their actual and future role in diagnosing dementia.AimTo explore Dutch GPs’ perceptions of their current position in diagnosing dementia, their reasons for referral to secondary care, and views on the future diagnostic role of GPs.MethodEighteen GPs participated in a semi-structured interview that ranged from 20 to 60 minutes. Interviews were transcribed verbatim and thematic analysis was performed.ResultsGPs reported that their role in the diagnostic phase of identifying people with suspected dementia is limited to recognising cognitive problems and deciding whether a patient needs to be referred for further investigation, or whether care could be organised without specialist diagnosis. GPs indicated that they were likely to refer patients if patients/caregivers or dementia case managers requested it, or if they thought it could have consequences for treatment. Typically, GPs do not see the need for referral when their patients are very old and declining slowly. GPs would welcome a more prominent role in diagnosing dementia in their own practice.ConclusionDiagnosing dementia involves a complex balance between patient and carer preferences, the consequences for treatment and care, and the burden of referral. Dutch GPs favour a stronger involvement in diagnosing dementia provided that both resources and diagnostic algorithms are improved.     

Childhood long-term conditions in primary care: a qualitative study of practitioners’ views

Background

Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.

Aim

To explore practitioners’ views of supporting children with LTCs and their families in primary care.

Design and setting

Qualitative interview study in primary care settings in South Yorkshire, England.

Method

Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.

Results

Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.

Conclusion

Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners.     

Physician self-disclosure in primary care: a mixed methods study of GPs’ attitudes,skills, and behaviour

Background

There is a debate in medicine about the use and value of self-disclosure by the physician as a communication tool. There is little empirical evidence about GPs and self-disclosure.

Aim

To explore what GPs’ attitudes, skills, and behaviour are with regard to self-disclosure during a clinical consultation and whether there is a need for the development of training resources.

Design and setting

Mixed methods using open-ended and semi-structured interviews in Auckland, New Zealand, and the surrounding districts.

Method

Sixteen GPs were interviewed on the issue of self-disclosure in clinical practice. A general inductive approach was used for data analysis.

Results

Self-disclosure was common in this group of GPs, contrary to training in some of the groups, and was seen as a potentially positive activity. Family and physical topics were most common, yet psychological and relationship issues were also discussed. Knowing patients made self-disclosure more likely, but a GP’s intuition played the main role in determining when to self-disclose, and to whom. GPs have developed their own guidelines, shaped by years of experience; however, there was a consensus that training would be helpful.

Conclusion

Self-disclosure is common and, in general, seen as positive. Major personal issues were acceptable for some GPs to self-disclose, especially to known patients. Although participants had developed their own guidelines, exposure of trainees to the issue of self-disclosure would be of value to prevent future mistakes and to protect both doctor and patient from any unintended harm, for example, developing a dependent relationship.     

Influence of primary care practices on patients’ uptake of diabetic retinopathy screening: a qualitative case study

Background

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes in England by enabling prompt diagnosis of sight-threatening retinopathy. However, the rate of screening uptake between practices can vary from 55% to 95%. Existing research focuses on the impact of patient demographics but little is known about GP practice-related factors that can make a difference.

Aim

To identify factors contributing to high or low patient uptake of retinopathy screening.

Design and setting

Qualitative case-based study; nine purposively selected GP practices (deprived/affluent; high/low screening uptake) in three retinopathy screening programme areas.

Methods

Semi-structured interviews were conducted with patients, primary care professionals, and screeners. A comparative case-based analysis was carried out to identify factors related to high or low screening uptake.

Results

Eight possible factors that influenced uptake were identified. Five modifiable factors related to service and staff interactions: communication with screening services; contacting patients; integration of screening with other care; focus on the newly diagnosed; and perception of non-attenders. Three factors were non-modifiable challenges related to practice location: level of deprivation; diversity of ethnicities and languages; and transport and access. All practices adopted strategies to improve uptake, but the presence of two or more major barriers made it very hard for practices to achieve higher uptake levels.

Conclusions

A range of service-level opportunities to improve screening attendance were identified that are available to practices and screening teams. More research is needed into the complex interfaces of care that make up retinopathy screening.     

Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions

Background

Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim

To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting

Qualitative study in urban and semi-rural areas of north-west England.

Method

Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results

All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion

Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.     

Patients’ experiences of using a smartphone application to increase physical activity: the SMART MOVE qualitative study in primary care

Background

Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour.

Aim

To explore patients’ views and experiences of using smartphones to promote physical activity in primary care.

Design and setting

This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland.

Method

Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data.

Results

Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the ‘Know-Check-Move’ effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants.

Conclusion

Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants’ relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities.     

Operationalising unscheduled care policy: a qualitative study of healthcare professionals’ perspectives

Background

UK health policy aims to reduce the use of unscheduled care, by increasing proactive and preventative management of patients with long-term conditions in primary care.

Aim

The study explored healthcare professionals’ understanding of why patients with long-term conditions use unscheduled care, and the healthcare professionals’ understanding of their role in relation to reducing the use of unscheduled care.

Design and setting

Qualitative study interviewing different types of healthcare professionals providing primary care or unscheduled care services in northwest England.

Method

Semi-structured interviews were conducted with 29 healthcare professionals (six GPs; five out-of-hours GPs; four emergency department doctors; two practice nurses; three specialist nurses; two district nurses; seven active case managers). Data were analysed using framework analysis.

Results

Healthcare professionals viewed the use of unscheduled care as a necessary component of care for patients with long-term conditions. Those whose roles involved working to targets to reduce the use of unscheduled care described a tension between this and delivering optimum patient care. Three approaches to reducing unscheduled care were described: optimising the system; negotiating the system; and optimising the patient.

Conclusion

Current policy to reduce the use of unscheduled care does not take account of the perceptions of the healthcare professionals who are expected to implement them. Lipsky’s theory of street-level bureaucrats provides a framework to understand how healthcare professionals respond to imposed policies. Healthcare professionals did not see the use of unscheduled care as a problem and there was limited commitment to the policy targets. Therefore, policy should aim for whole-system change rather than reliance on individual healthcare professionals to make changes in their practice.     

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.     

Reassured or fobbed off? Perspectives on infertility consultations in primary care: a qualitative study

Background

Infertility affects 9% of couples in the UK. Most couples who visit their GP because they are worried about their fertility will ultimately conceive, but a few will not. Treatment usually happens in secondary care, but GPs can have an invaluable role in starting investigations, referring, and giving support throughout treatment and beyond.

Aim

To inform clinical practice by exploring primary care experiences of infertility treatment among females and males, and discussing findings with a reference group of GPs to explore practice experience.

Design and setting

A qualitative patient interview and GP focus group study. Interviews were conducted in patients homes in England and Scotland; the focus group was held at a national conference.

Method

An in-depth interview study was conducted with 27 females and 11 males. A maximum variation sample was sought and interviews were transcribed for thematic analysis. Results were discussed with a focus group of GPs to elicit their views.

Results

Feeling that they were being taken seriously was very important to patients. Some felt that their concerns were not taken seriously, or that their GP did not appear to be well informed about infertility. The focus group of GPs highlighted the role of protocols in their management of patients who are infertile, as well as the difficulty GPs faced in communicating both reassurance and engagement.

Conclusion

Simple things that GPs say and do, such as describing the ‘action plan’ at the first consultation, could make a real difference to demonstrating that they are taking the fertility problem seriously.     

Dying at home: a qualitative study of family carers’ views of support provided by GPs community staff

Background

Dying at home is the preference of many patients with life-limiting illness. This is often not achieved and a key factor is the availability of willing and able family carers.

Aim

To elicit family carers’ views about the community support that made death at home possible.

Design and setting

Qualitative study in East Devon, North Lancashire, and Cumbria.

Method

Participants were bereaved family carers who had provided care at the end of life for patients dying at home. Semi-structured interviews were conducted 6–24 months after the death.

Results

Fifty-nine bereaved family carers were interviewed (54% response rate; 69% female). Two-thirds of the patients died from cancer with median time of home care being 5 months and for non-cancer patients the median time for home care was 30 months. An overarching theme was of continuity of care that divided into personal, organisational, and informational continuity. Large numbers and changes in care staff diluted personal continuity and failure of the GPs to visit was viewed negatively. Family carers had low expectations of informational continuity, finding information often did not transfer between secondary and primary care and other care agencies. Organisational continuity when present provided comfort and reassurance, and a sense of control.

Conclusion

The requirement for continuity in delivering complex end-of-life care has long been acknowledged. Family carers in this study suggested that minimising the number of carers involved in care, increasing or ensuring personal continuity, and maximising the informational and organisational aspects of care could lead to a more positive experience.     

Understanding of family medicine in Africa: a qualitative study of leaders’ views

Background

The World Health Organization encourages comprehensive primary care within an ongoing personalised relationship, including family physicians in the primary healthcare team, but family medicine is new in Africa, with doctors mostly being hospital based. African family physicians are trying to define family medicine in Africa, however, there is little clarity on the views of African country leadership and their understanding of family medicine and its place in Africa.

Aim

To understand leaders’ views on family medicine in Africa.

Design and setting

Qualitative study with in-depth interviews in nine sub-Saharan African countries.

Method

Key academic and government leaders were purposively selected. In-depth interviews were conducted using an interview guide, and thematically analysed.

Results

Twenty-seven interviews were conducted with government and academic leaders. Responders saw considerable benefits but also had concerns regarding family medicine in Africa. The benefits mentioned were: having a clinically skilled all-rounder at the district hospital; mentoring team-based care in the community; a strong role in leadership and even management in the district healthcare system; and developing a holistic practice of medicine. The concerns were that family medicine is: unknown or poorly understood by broader leadership; poorly recognised by officials; and struggling with policy ambivalence, requiring policy advocacy championed by family medicine itself.

Conclusion

The strong district-level clinical and leadership expectations of family physicians are consistent with African research and consensus. However, leaders’ understanding of family medicine is couched in terms of specialties and hospital care. African family physicians should be concerned by high expectations without adequate human resource and implementation policies.