Shared care: a qualitative study of GPs' and hospital doctors' views on prescribing specialist medicines.

BACKGROUND: Shared care schemes have mainly centred on chronic diseases, such as asthma and diabetes. However, with increasing government emphasis on primary and secondary care integration and the effects of budget restraints, general practitioners (GPs) have been asked to take on the prescribing of specialist medicines. AIM: To elicit the views and experiences of GPs and hospital doctors about existing arrangements for shared care applied to the prescribing of specialist medicines. To identify a set of quality indicators for prescribing specialist medicines at the interface between primary and secondary care. DESIGN OF STUDY: A qualitative study based on semi-structured interviews. SETTING: Forty-eight GPs and 13 hospital doctors in the former South Thames region. METHOD: The interviews focused on how far experiences with shared care compare with the arrangements currently in place for prescribing specialist medicines and identified the barriers to facilitators of effective shared care. RESULTS: A number of key themes were identified and these formed the basis for eight quality indicators relating to the prescribing of specialist medicines where treatment is shared between primary and secondary care. The themes centred around issues of clinical responsibility, 'cost-shifting', availability of medicines, GP satisfaction, and the nature of the prescribing relationship. CONCLUSION: Overall, GPs appeared dissatisfied with arrangements for prescribing specialist medicines, while hospital doctors were generally satisfied. The quality indicators will form the basis of a more extensive quantitative survey of GPs' perceptions of the arrangements for prescribing specialist medicines.     

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services.

BACKGROUND: General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning. AIM: To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided. METHOD: A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received. RESULTS: Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs. CONCLUSION: The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.     

Primary care units in A&E departments in North Thames in the 1990s: initial experience and future implications.

BACKGROUND: In 1992, the Tomlinson Report recommended a shift from secondary to primary care, including specific primary care provision in accident and emergency (A&E) departments. Availability of short-term so-called Tomlinson moneys allowed a number of experimental services. A study of the experience of A&E-based staff is reported to assist general practitioners (GPs) and purchasers and identify areas for further research. AIMS: To find the number and scope of primary care facilities in A&E services in North Thames; to find factors encouraging or inhibiting the setting-up of a successful service; to examine the views of a range of A&E staff including GPs, consultants, and nurses; and to suggest directions for more specific research. METHOD: A postal questionnaire was sent to all North Thames A&E departments, and an interview study of staff in one unit was arranged, leading to a questionnaire study of all GPs employed in North Thames primary care services in A&E. This was followed by interviews of staff members in five contrasting primary care units in A&E. RESULTS: By mid-1995, at least 16 of the 33 North Thames A&E departments ran a primary care service. Seven mainly employed GPs, the others employed nurse practitioners (NPs). Problems for GPs included unclear role definition and their non-availability at times of highest patient demand. GPs' reasons for working in A&E sometimes differed from the aims of primary care in an A&E service. Staff interviews revealed differing views about their role and about use of triage protocols. Ethnicity data were being collected, but not yet being used, to improve service to patients. CONCLUSIONS: A number of benefits follow the introduction of primary care practitioners into A&E. Different models have evolved, with a variety of GP and NP staffing arrangements according to local ideas and priorities. There is some confusion over whether these services aim to improve A&E-based care or to divert it to general practice. Cost information is inadequate so far, though the use of GPs has shown the possibility of economy. Appropriate location of services requires clearer identification of costs. This may be possible for the proposed primary care groups.     

A qualitative study of barriers to the use of statins and the implementation of coronary heart disease prevention in primary care.

BACKGROUND: Statin prescribing to prevent coronary heart disease is well below recommended levels. Studies suggest that the prescribing behaviour of doctors may be the biggest factor in the wide variation in statin prescribing in general practice. Understanding doctors' perceptions offers some insight into why variation occurs. AIM: To understand general practitioners' (GPs') views about barriers to statin prescribing, statin prescribing guidelines, and the successes and barriers to coronary prevention in primary care. DESIGN OF STUDY: Qualitative analysis of semi-structured interviews. SETTING: General practices in mid and south Bedfordshire. METHOD: Interviews with 26 GPs. RESULTS: GPs spoke of a variety of barriers to initiating statin treatment specifically, and coronary heart disease prevention generally. Barriers to statin prescribing included: concerns about cost; increased workload and adherence to treatment; variation in treatment targets for lowering cholesterol; and concerns about medicalisation, lifestyle, and health behaviour. GPs found it difficult to prioritize patients for statin treatment, their statin treatment targets varied, and many found primary prevention risk assessment tools difficult to interpret. Coronary prevention was limited by practice space and organisational issues, by problems with recording and retrieval of electronic data, and by limited doctor and nurse time. GPs suggested that funded nurse time, nurse-led heart disease clinics, and better use of electronic data would improve primary care coronary prevention. CONCLUSION: There are complex barriers to statin prescribing and coronary prevention in general practice, which may explain some of the variation that exists. Further studies of patients' views of statins may provide more information. More resources, improved guidance, and better dissemination of guidance may only address some of the issues.     

Interprofessional relationships and communication in primary palliative care: impact of the Gold Standards Framework.

BACKGROUND: High quality end-of-life care in the community is achieved with effective multidisciplinary teamwork, interprofessional communication between GPs and district nurses, and early referral of patients to district nurses. These aspects of palliative care are highlighted in the Gold Standards Framework, a programme recently established in UK primary care. AIM: To investigate the extent to which the framework influences interprofessional relationships and communication, and to compare GPs' and nurses' experiences. DESIGN OF STUDY: Qualitative interview case study. SETTING: Fifteen participating practices from three primary care trusts in England. METHOD: Thirty-eight semi-structured interviews were undertaken with GPs, district nurses, Macmillan nurses, and framework facilitators. RESULTS: Adoption of the framework often resulted in earlier referral of palliative care patients to district nurses. Multidisciplinary team meetings enabled communication for sharing knowledge, discussing management problems, and keeping colleagues informed; however, arranging and maintaining such meetings was often problematic. Nurses particularly valued formal meetings while GPs generally preferred informal ad hoc dialogue. GPs largely maintained control of the mode of multidisciplinary working. The best functioning teams used a mixture of formal and informal meetings with a relatively non-hierarchical working style. CONCLUSION: Implementing the framework enabled processes of communication associated with high quality palliative care in general practice, but there was marked variation in how this worked in individual teams. In general, hierarchical doctor-nurse relationships persisted.     

GPs' approach to insulin prescribing in older patients: a qualitative study

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.     

Nurse case management and general practice: implications for GP consortia

Background

Case management is widely promoted as a means of ensuring continuity of care, improving patient outcomes, and achieving efficient management of resources. Community matrons have been introduced recently as specialists in the case management of patients with multiple complex problems.

Aim

To understand how nurse case managers are seen by GPs and NHS managers.

Setting

(1) Telephone interviews with 41 community nurse managers recruited from 10 English strategic health authorities and two Welsh health boards; (2) face-to-face interviews with 12 nurse case managers, 12 GPs and five NHS community service managers in three study sites with different population and practitioner characteristics.

Method

Semi-structured individual interviews, by telephone or face to face.

Results

Attitudes among GPs to nurse case managers were shaped by perceptions of the quality of community nursing on the one hand and the perceived benefit of case management as a method of reducing hospital use on the other. The dominant mood was scepticism about the ability of nurse case managers to reduce hospital admissions. Community matrons were seen as staff who were imposed on local health services, sometimes to detrimental effect.

Conclusion

The introduction of case management and community matrons may disrupt existing communities of practice and be perceived negatively, at least in areas where good working relationships between nurses and GPs have developed. Commissioners should be aware of the potential resistance to changes in skill mix and role in nursing services, and promote innovation in ways that minimise disruption to functional communities of practice.     

Experiences of general practitioners and practice nurses of training courses in evidence-based health care: a qualitative study.

BACKGROUND: Clinical governance will require general practitioners (GPs) and practice nurses (PNs) to become competent in finding, appraising, and implementing research evidence--the skills of evidence-based health care (EBHC). AIM: To report the experiences of GPs and PNs in training in this area. METHOD: We held 30 in-depth, semi-structured interviews throughout North Thames region with three groups of informants: primary care practitioners recruited from the mailing lists of established EBHC courses; organizers and teachers on these courses; and educational advisers from Royal Colleges, universities, and postgraduate departments. Detailed qualitative analysis was undertaken to identify themes from each of these interview groups. RESULTS: At the time of the fieldwork for this study (late 1997), remarkably few GPs or PNs had attended any formal EBHC courses in our region. Perceived barriers to attendance on courses included inconsistency in marketing terminology, cultural issues (e.g. EBHC being perceived as one aspect of rapid and unwanted change in the workplace), lack of confidence in the subject matter (especially mathematics and statistics), lack of time, and practical and financial constraints. Our interviews suggested, however, that the principles and philosophy of EBHC are beginning to permeate traditional lecture-based continuing medical education courses, and consultant colleagues increasingly seek to make their advice 'evidence based'. CONCLUSION: We offer some preliminary recommendations for the organizers of EBHC courses for primary care. These include offering a range of flexible training, being explicit about course content, recognizing differences in professional culture between primary and secondary care and between doctors and nurses, and addressing issues of funding and accreditation at national level. Introducing EBHC through traditional topic-based postgraduate teaching programmes may be more acceptable and more effective than providing dedicated courses in its theoretical principles.     

The compatibility of prescribing guidelines and the doctor-patient partnership: a primary care mixed-methods study

Background

UK policy expects health professionals to involve patients in decisions about their care (including medicines use) and, at the same time, to follow prescribing guidelines. The compatibility of these approaches is unclear.

Aim

To explore the relationship between prescribing guidelines and patient-partnership by exploring the attitudes of patients, GPs and primary care trust (PCT) prescribing advisors.

Design and setting

A mixed-methods study using qualitative, semi-structured interviews followed by a quantitative, questionnaire survey in primary care in Northern England.

Method

Interviews were conducted with 14 patients taking a statin or a proton pump inhibitor, eight GPs and two prescribing advisors. A multi-variate sampling strategy was used. Qualitative findings were analysed using framework analysis. Questionnaires based on themes derived from the interviews were distributed to 533 patients and 305 GPs of whom 286 (54%) and 142 (43%) responded.

Results

Areas of tension between guidelines and patient partnership were identified, including potential damage to trust in the doctor and reduced patient choice, through the introduction of the policy maker as a third stakeholder in prescribing decisions. Other areas of tension related to applying single condition guidelines to patients with multiple illnesses, competition for doctors'' time and the perception of cost containment. Many GPs coped with these tensions by adopting a flexible approach or prioritising the doctor–patient relationship over guidelines.

Conclusion

Rigidly applied guidelines can limit patient choice and may damage the doctor–patient relationship. GPs need flexibility in order to optimise the implementation of prescribing guidelines, while responding to individuals'' needs and preferences.     

Can primary care groups learn how to manage demand from fundholders? A study of fundholders in Nottingham.

BACKGROUND: Primary care groups (PCGs) will commission care for their patients and may be increasingly required to manage clearly defined resources. Existing general practice fundholders already operate in this environment, but can PCGs learn from the experience of fundholders in managing demand? AIM: To explore how general practice fundholders manage demand for hospital and community health services, and for prescribing. METHOD: A general practitioner (GP), and a fundholding manager from each of 26 practices were invited to take part. Questionnaires were developed, with structured and semi-structured components, and piloted in three practices. Interviews were conducted between October 1996 and February 1997 by the same interviewer (MDT). RESULTS: All practices stated that they were monitoring their waiting lists and giving priority to patients whose problems had become worse, but eight of the 23 GPs felt that they were unable to manage demand. Eight of the 15 fundholders who had developed in-house services actively managed the waiting list for these clinics. All fundholders had identified areas of unmet demand. Widely differing methods for increasing supply to meet demand were identified, and are described. Formularies were used by 12 out of the 23 fundholders. Guidelines were only considered useful by eight of the 23 practices; fundholders from later waves were less likely to find guidelines useful than fundholders from earlier waves (odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0 to 0.96). Private specialist surgery was less likely to be accessed by later wave fundholders using the fund than by early wave fundholders (OR = 0.10; 95% CI = 0.09 to 0.97). CONCLUSION: Fundholders in Nottingham had not developed consistent approaches to managing demand within limited resources. Given the apparent diversity of attitudes and practices, the larger PCGs will require strong support to develop the intended commissioning function.     

A qualitative study to explore influences on general practitioners'' decisions to prescribe new drugs.

BACKGROUND: Ensuring appropriate prescribing is an important challenge for the health service, and the need for research that takes account of the reasons behind individual general practitioners' (GPs) prescribing decisions has been highlighted. AIM: To explore differences among GPs in their decisions to prescribe new drugs. DESIGN OF STUDY: Qualitative approach, using in-depth semistructured interviews. SETTING: Northern and Yorkshire Health Authority Region. METHOD: Participants were identified from a random sample of 520 GPs in a quantitative study of patterns of uptake of eight recently introduced drugs. Purposeful sampling ensured inclusion of GPs prescribing any of the eight drugs and working in a range of practice settings. Fifty-six GPs were interviewed, using a topic guide. Interviews were recorded on audiotape. Transcribed text was methodically coded and data were analysed by constantly comparing emerging themes. RESULTS: Both low and high prescribers shared a view of themselves as conservative in their prescribing behaviour. Low prescribers appeared to conform more strongly to group norms and identified a consensus among practice partners in prescribing and cost-consciousness. Conformism to group norms was represented by a commitment to practice formularies. High prescribers more often expressed themselves to be indifferent to drug costs and a shared practice ethos. CONCLUSIONS: A shift in the attitudes of some GPs is required before cost-effectiveness is routinely incorporated in drug prescribing. The promotion of rational prescribing is likely to be more successful if efforts are focused on GPs' appreciation of cost issues and attitudes towards shared decision-making and responsibility.     

When questionnaire response rates do matter: a survey of general practitioners and their views of NHS changes.

This paper investigates whether general practitioners (GPs) who do not participate in questionnaire surveys (non-responders) hold different views on participation in primary care reorganisation than their more compliant colleagues. A survey of 72 GPs' involvement in a pilot primary care prescribing group elicited an initial response of 74%. Non-responders were then approached personally and persuaded to complete the questionnaire. Comparison of the responders and the non-responders showed that the latter did differ significantly from the responders in many of their views. This difference needs to be considered whenever the results of surveys are used to guide policy-making in the more corporate model of primary care that is now emerging.     

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.     

A proposal to use a balanced scorecard to evaluate Information for Health: an information strategy for the modern NHS (1998-2005)

The author was invited to assist in the development of an evaluation methodology for the Strategy. One of the conundrums of measuring the information management & technology (IM&T) function is that infrastructure investments cannot be cost justified on a return on investment basis. The balanced scorecard (BSC) is a means to evaluate corporate performance from four different perspectives: the financial perspective, the internal business process perspective, the customer perspective, and the learning and growth perspective. An IM&T BSC for Information for Health was recommended as means of allowing managers to see the positive and negative impacts of IM&T activities on the factors that are important to the NHS as a whole.     

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.     

How do teenagers and primary healthcare providers view each other? An overview of key themes.

BACKGROUND: Teenagers have often been asked for their opinions about health services. However, relatively few studies have involved quantitative and qualitative methods of assessing them. Furthermore, there have been no United Kingdom studies of providers' views on the health of teenagers or of providers' opinions about their role in teenage health. AIM: To determine how teenagers view primary care, to discover how primary care providers view teenage patients, and to note any differences in opinions between the two groups. DESIGN OF STUDY: Questionnaire survey, focus group discussions, and semi-structured interviews. SETTING: Two thousand two hundred and sixty-five teenage patients, 16 general practitioners (GPs), 12 practice nurses, and 12 general practice receptionists in South Wales valley communities. METHOD: Selected practices provided age-sex registers of patients aged between 14 and 18 years and questionnaires were sent to these patients. Focus groups were assembled from those teenagers who had completed and returned the questionnaire. Semi-structured interviews between one member of the study team and GP surgery staff, chosen randomly from staff lists in the selected surgeries. RESULTS: The teenagers reported a lack of knowledge of services available from primary care, a feeling of a lack of respect for teenage health concerns, poor communication skills in GPs, and a poor understanding of confidentiality issues. The providers did not always share these concerns and they also had differing views on communication and confidentiality issues. CONCLUSION: The data demonstrated important findings about how teenagers would like primary care services to be improved. There was an apparent gulf between teenagers' own opinions about health care and the opinions held by primary care providers.     

Needs assessment in primary care: general practitioners' perceptions and implications for the future.

BACKGROUND: Health needs assessment can guide the appropriate shift to primary care by identifying the most effective and efficient resource allocation to meet the needs of populations. Assessing health care needs will be a continuing challenge for primary care trusts in Scotland (or equivalent groups in other parts of the United Kingdom); however, lessons must be learned from the experience of needs assessment that followed the 'internal market' reforms of the 1990s. AIM: To examine general practitioners' (GPs') awareness and experience of needs assessment, to identify barriers to needs assessment in primary care, and to ascertain how better progress might be made in the future. METHOD: A postal questionnaire survey of 1777 Scottish GPs (a one-in-two sample) was combined with a semistructured interview survey of 'lead' GPs from a random sample of 64 mainland Scottish practices between May and August 1996. RESULTS: Sixty-five per cent (1154) of GPs responded to the questionnaire, of which 54% (965) were completed. Over 73% (47) of interviews were completed. Most GPs were unfamiliar with the concept of needs assessment and there was no evidence that needs assessment had influenced commissioning decisions. Most GPs argued that it was not a 'core' activity and that they lacked training in the relevant skills. While the attitude of the majority was indifferent, cynical, and sometimes hostile, a minority, comprising mostly younger fundholders, was more enthusiastic about needs assessment. CONCLUSION: The motivation and attitude of the majority of GPs present a barrier to needs assessment in primary care. GPs will require more resources and training if they are to undertake this responsibility. Most GPs believe than incentives (financial or organisational) will be necessary. Primary care trusts and equivalent structures should be aware of these attitudes as they seek to establish plans based on estimates of population needs in defined locations.