“90% of the time,it’s not just weight”: General practitioner and practice staff perspectives regarding the barriers and enablers to obesity guideline implementation

ObjectiveTo identify the views of GPs and general practice staff regarding barriers and enablers to implementation of obesity guideline recommendations in general practice.MethodsTwenty general practitioners (GPs) and 18 practice staff from inner-eastern Melbourne, Australia, participated in semi-structured telephone interviews. The interview schedule was informed by the Theoretical Domains Framework (TDF). Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis.ResultsParticipants lacked familiarity with and knowledge of the NHMRC obesity guidelines. Barriers and enablers were predominantly related to five theoretical domains: (1) environmental context and resources, (2) knowledge, (3) emotion, (4) beliefs about consequences, and (5) motivation and goals. Time pressures in consultations, costs for the patient, reluctance to add to patient burden particularly in those with comorbidities such as mental health issues, lack of awareness about services to refer patients to and GPs’ fear of embarrassing patients and losing them were significant barriers. Enablers included having a strong doctor–patient relationship and a sense of responsibility to the patient to address weight.ConclusionsObesity guidelines and policy makers need to better engage with issues of multimorbidity, socioeconomic disadvantage and workforce issues if recommendations are to be widely adopted in general practice. Tasksharing, teamwork and technology are potential solutions to some of the barriers. Patient perspectives and approaches to being able to overcome stigma and legitimise obesity management in primary care consultations could also assist.     

"Opening a can of worms": GP and practice nurse barriers to talking about sexual health in primary care

BACKGROUND: There is evidence that health professionals do not discuss sexually related issues in consultations as often as patients would like. Although primary care has been identified as the preferred place to seek treatment for sexual health concerns, little is known either of the factors that prevent GPs and practice nurses initiating such discussions or of how they feel communication in this area could be improved. OBJECTIVE: The purpose of the present study was to identify barriers perceived by GPs and practice nurses to inhibit discussion of sexual health issues in primary care and explore strategies to improve communication in this area. METHODS: Semi-structured interviews were conducted with 22 GPs and 35 practice nurses recruited from diverse practices throughout Sheffield. RESULTS: The term 'can of worms' summarized participants' beliefs that sexually related issues are highly problematic within primary care because of their sensitivity, complexity and constraints of time and expertise. Particular barriers were identified to discussing sexual health with patients of the opposite gender, patients from Black and ethnic minority groups, middle-aged and older patients, and non-heterosexual patients. Potential strategies to improve communication about sexual health within primary care included training, providing patient information and expanding the role of the practice nurse; however, several limitations to these approaches were identified. CONCLUSION: GPs and practice nurses do not address sexual health issues proactively with patients, and this area warrants further attention if policy recommendations to expand the role of primary care within sexual health management are to be met.     

Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study

Background

Approximately one in ten of the UK population are unpaid carers supporting a family member or friend who could not manage without their help, saving the UK economy an estimated £87 billion. This role is known to sometimes have a negative impact on carers and to require support both informally and from statutory services. General practice is a first point of contact for carers but research investigating general practitioners' (GPs') attitudes towards carers and awareness of issues facing carers is rare. This study therefore aimed to identify GPs' attitudes, awareness of issues, and perceptions of the barriers and enablers to provision of services.

Methods

Using a self-completion questionnaire distributed at a series of workshops, this study investigates GPs' attitudes to carers; awareness and knowledge of carers' issues; services offered in general practice and barriers to supporting carers.

Results

Seventy eight out of a total of 95 GPs (82% response rate) from a variety of areas in England completed the questionnaires. The GPs identified time, resources and lack of knowledge as barriers, but only 9% agreed with the statement that there is little support they can offer carers. However, nine in ten GPs (89%) feel they have insufficient training here and approximately half of them (47%) lack confidence that they are meeting carers' needs. Confidence in identifying carers is also low (45%). Issues that GPs would look out for amongst carers include emotional and physical health problems and financial and isolation difficulties. GPs specifically highlighted educational and isolation issues for young carers. Few services were described that targeted carers.

Conclusions

GPs recognise that they have an important role to play in supporting carers but would like training and support. Further investigation is needed both to determine how best to train and facilitate GPs and general practice teams in their role in supporting carers and to identify what carers need and want from general practice. Identifying carers' leads or carers' champions amongst practice staff is possibly one way forward. Given the proposed greater commissioning role for primary care, greater understanding here is particularly important.     

General practitioners,primary care and support for carers in England: can training make a difference?

As a part of the national carers' strategy, the Department of Health commissioned six pilot workshops spread across England for General Practitioners (GPs) and other primary healthcare workers. The six workshops were held during September and October 2009, arranged by the Royal College of General Practitioners and planned in consultation with the Princess Royal Trust for Carers. The workshops were delivered by one of two GPs and by a carer. The Department of Health commissioned an evaluation of the workshop programme. This paper reports on the attitudes towards and knowledge of carers by GPs and other primary care workers, such as community matrons, practice nurses, healthcare assistants, practice managers and receptionists. It also tracks changes over time from the questionnaire responses pre- and post-workshop and 3 months later in the GPs' and other primary care workers' response to carers. Prior to the workshops, GPs and other primary care workers saw primary care as having a significant role in directly assisting carers, especially with emotional support and in signposting to other services. However, there was a lack of knowledge about issues facing carers, limited confidence in assisting carers and few services within the primary care teams directly focussed on carers. The workshops were regarded positively by those who attended, and the evaluation found that there was a positive impact with GPs and other primary care workers reporting specific actions they had taken post-workshop to assist carers, greater confidence and awareness in working with carers, and increased knowledge about carers. The paper concludes by recommending how the pilot programme might be rolled out more widely.     

What impact will an increased number of teaching general practices have on patients,doctors and medical students?

BACKGROUND: Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community - primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching. AIM: To explore the perceptions of primary care staff on the impact that increasing student numbers will have on them, on their patients and on the students themselves. DESIGN OF STUDY: Semi-structured interviews. SETTING: Three general practices presently involved in undergraduate teaching, 3 practices about to become involved in undergraduate teaching and 1 non-teaching practice, all in the Black Country area of the West Midlands. METHODS: Semi-structured interviews with prearranged prompts were undertaken with a variety of practice staff including general practitioners (GPs), practice managers and practice nurses, as well as administrative and reception staff. RESULTS: Eleven GPs, 6 practice managers, 4 practice nurses and 6 receptionists/administrators took part in the interviews. Three main themes emerged relating to the effects on students and reflecting attitudes towards the Black Country, the experience of working among deprived populations and issues around access to the new training locations. The majority of interviewees were of the opinion that patients both enjoy taking part in undergraduate teaching and are able to benefit from the process. Positive impacts on practice infrastructure were also elicited, but when asked about the resource implications for the practice of undergraduate teaching, there was a dichotomy of opinion. CONCLUSION: For many practices, involvement in undergraduate teaching is a double-edged sword.     

Poor communication may impair optimal asthma care: a qualitative study

BACKGROUND: Despite asthma being primarily managed in general practice and primary care, there is little research into the issues and tools which may impact on managing poorly controlled asthma in this setting. OBJECTIVE: To explore the views of health care professionals (HCPs) towards asthma guidelines and self-management plans (SMPs) to identify why these are not used routinely in general practice. METHODS: Data from 54 HCPs [GPs and practice nurses (PNs)] in north-east Scotland were collected via qualitative interviews and focus groups. Participant views and experience of asthma guidelines and SMPs were explored. RESULTS: Participants had mainly positive attitudes towards guidelines and SMPs, although both were used only when deemed suitable by the individual. Suitability depended on individual patient issues (e.g. psychosocial factors, level of control) and/or professional issues (e.g. ease of use, time available, job roles). Patient issues were viewed as impacting on asthma control directly and, indirectly, as the main reason for not using guidelines or SMPs with a patient. HCPs reported lacking necessary communication skills for dealing with patient asthma control issues, particularly where these were non-medical. Professional and organizational issues such as training and communication were also perceived as impairing asthma management. CONCLUSION: Our findings indicate that guidelines are seen as providing the 'why' of helping asthma patients' self-manage but not the 'what to...' or 'how to...' communicate. Poor professional-patient communication seems largely to explain the poor uptake of SMPs and guideline use in general practice and primary care. This limitation is more obvious to professionals when they are working with patients with poorly controlled asthma. There is a need to identify key communication skills for effective professional-patient partnership in adult asthma management, and to develop robust strategies for effectively training GPs and PNs in enhancing these skills.     

Advanced access: more than just GP waiting times?

BACKGROUND: Advanced access has been forwarded as a strategy for reducing waiting times in primary care; however, previous evaluations have raised important issues regarding its appropriateness. OBJECTIVES: The objectives of this paper are to assess the impact of advanced access on patient access to primary care services, and its broader effects on stakeholders. METHODS: A quantitative analysis of appointment data on 462 practices implementing advanced access, together with qualitative analysis of open survey responses and interviews with 28 practice staff. Appointment data recorded time to third available appointment for GP and practice nurse, together with the percentage of patients seen on their day of choice. Themes were identified from the interviews and survey responses and related to issues identified in previous research. RESULTS: The implementation of advanced access was associated with reductions in time to see practice nurses as well as GPs, and increases in the proportion of patients being seen on their day of choice. Interviewee and survey responses suggested that practice population characteristics may impact on the model, and some patient groups may be disadvantaged from the changes in the appointment systems seen in this study. Whilst experiences were mixed, the potential for broader changes to working practices of all practice staff was evident. CONCLUSIONS: In general, these results suggest that advanced access can have a positive impact across several aspects of primary care services, and not just the availability of GP appointments. However, it also highlights some problems, in that waiting times worsened in some practices and there were concerns that some vulnerable groups may be disadvantaged.     

Telephone triage by nurses in primary care: what is it for and what are the consequences likely to be?

OBJECTIVES: To examine the perceptions that those working in primary care have about the purpose and impact that telephone triage by nurses may have on their clinical roles and identities. METHODS: Twenty-six semi-structured interviews were carried out with general practitioners (GPs), practice nurses and practice managers from a purposive sample of nine practices in one health district in the North West of England. Analysis drew on the techniques of constant comparison and discourse analysis. RESULTS: Four themes emerged from the data: justifying triage - the respondents justify the introduction of telephone triage by emphasising the managerial benefits of controlling access and by suggesting the benefits this may bring to the patient-clinician relationship; categorising patients - patients are categorised and allocated on the basis of their biomedical diagnoses to the nurses or GPs in the practice; changing roles and identities - the hierarchy of patients and conditions created by allocating patients in this way strengthens and extends the professional hierarchy within a practice; and achieving a balance between conflicting aims - there is tension between the managerial need to triage patients according to their biomedical diagnosis and the aspirations that health care professionals have to personal and patient-centred care. CONCLUSION: Telephone triage by nurses may be effective at managing patient access to GPs but the need to categorise patients according to biomedical and managerial criteria needs to be balanced against the professional roles and identities that those working in general practice aspire to.     

From troglodytes to information managers: information management and technology needs to achieve the primary care NHS modernization agenda--the views of three GPs

In response to the information management and technology changes proposed by the Government's NHS modernization initiative this article examines the issues that GPs feel to be of major significance to their work. Although information and communications technology is widely used in general practice there is no one agreed standard system. The level of technology and the manner in which it is used is also diverse throughout the profession, as are the attitudes that exist amongst GPs regarding the value of information management and technology, and the benefits efficient information management offers to them and to their patients. The views of three local GPs from practices with varying levels of information technology were obtained through semi-structured interviews and the findings developed in the light of current discussions in the published literature. The GPs chosen reflect the disparity within general practice and, perhaps, other units of the NHS in the use and understanding of information management. The main conclusions were that there is ambivalence and scepticism about what NHSnet currently has to offer; that local electronic records benefit patient care, but when networked more widely problems of confidentiality and security result. Practitioners were also mindful of the financial costs of changes and concerned, given the impact of PCGs and clinical governance, as to who will be responsible for ensuring a common level of electronic records, IT provision, and financial and technological support.     

Nursing the patient with developmental disability in hospital: roles of paid carers

Our aim in this narrative inquiry was to understand the roles of paid carers supporting adults with developmental disability and complex communication needs in hospital, from the perspectives of 15 paid carers, 15 adults with developmental disability, and 15 hospital nurses. Results demonstrated that paid carers have an important role in supporting the adult with disability, providing information, delivering basic care, and facilitating communication. Stories reflected paid carer volunteerism; lack of orientation of carers and hospital staff to the paid carers' roles; blurred role boundaries between paid carers, family carers, and nurses; and paid carers being uncertain about their own responsibilities for staff and patient safety. New policies and practice guidelines are needed to guide both health and disability services in clarifying paid carer roles and role boundaries, and to enable paid carers and hospital staff to work together effectively on the ward in the care of adults with developmental disability.     

Total purchasing, community and continuing care: lessons for future policy developments in the NHS

The introduction of total purchasing pilots (TPPs) into the National Health Service (NHS) gave general practitioners (GPs) significant new opportunities to take responsibility for the development of community and continuing care (CCC) services. Based on five case studies of TPPs involved in developing CCC this paper asks three questions: (1) to what extent were the TPP’s involvement in CCC informed by an awareness of CCC policy?; (2) were TPPs involved in joint commissioning to develop integrated purchasing or provision which was informed by population based needs assessment?; (3) were TPPs seeking to involve users, carers and voluntary agencies in their plans? The findings indicate that TPPs showed little awareness of national or local policy for CCC, although their project initiatives did address some of the policy issues (in particular a recognition of the need for joint working at the practice level). At the time of fieldwork, four of the case study TPPs had begun to investigate the potential for integrated purchasing, and three of them had relatively sophisticated models of both horizontally and vertically integrated provision of care. However, the TPPs developments were not based on systematic population based needs assessment. The paper concludes that there is potential for the primary care led groups proposed in the recent white papers in England, Scotland and Wales to improve integration of care both horizontally and vertically. However, they may need policy guidance and push to: encourage them to put CCC high on their agenda for action; to work with people with expertise in population based, prevention focused, needs assessment; and to find innovative ways to include users, carers and voluntary agencies. Incentives or levers (such as control over budgets) may be needed to promote joint working between staff in different agencies.     

Co‐located welfare advice in general practice: A realist qualitative study

General practitioners (GPs) engage with patients about a variety of social issues distinct from direct clinical work (“non‐health” issues), such as health‐related benefits and debt. Co‐located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co‐located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty‐four semi‐structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non‐health work on practices: reduction of GP consultations linked to non‐health issues and reduced practice time spent on non‐health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre‐existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the “go‐to‐location”. We conclude that co‐location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co‐location to meet desired objectives.     

General practitioners’ perspectives on primary care consultations for suicidal patients

Little is known about general practitioners’ (GPs’) perspectives, management of and interactions with suicidal patients prior to the patient's suicide. The aims of the study were to explore GPs’ interpretations of patient communication and treatment in primary care leading up to suicide and to investigate the relationship between GPs and mental health services prior to a patient's suicide. Thirty‐nine semi‐structured interviews with GPs of people who had died by suicide were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using a thematic approach. The following themes emerged from GP interviews: (i) GP interpretations of suicide attempts or self‐harm; (ii) professional isolation; and (iii) GP responsibilities versus patient autonomy. GPs recruited for the study may have different views from GPs who have never experienced a patient suicide or who have experienced the death of a patient by suicide who was not under the care of specialist services. Our findings may not be representative of the rest of the United Kingdom, although many of the issues identified are likely to apply across services. This study highlighted the following recommendations for future suicide prevention in general practice: increasing GP awareness of suicide‐related issues and improving training and risk assessment skills; removing barriers to accessing therapies and treatments needed in primary care; improving liaison and collaboration between services to provide better patient outcomes; and increasing awareness in primary care about why patients may not want treatments offered by focusing on each individual's situational context.     

A sense of security for cancer patients at home: the role of community nurses

The present paper reports on a qualitative research project designed to expose the presently unrecognised minutiae of community nurses' work with cancer patients at home, and to identify the ways in which these, combined to form comprehensive care episodes, contribute to physical and psychosocial well-being. The project was conducted in two locations in New South Wales, Australia, one metropolitan and one rural. The research model focused on particular nurse-patient encounters, and involved pre- and post-encounter interviews with nurses, post-encounter interviews with patients and carers, and observation of the encounters themselves. Participants included generalist community nurses, cancer patients being cared for at home, and their primary carers where appropriate. This research demonstrates that regular contact with generalist community nurses is associated with a strong sense of security about the immediate situation for home-based cancer patients and their primary carers. This sense of security is a significant component of patient and carer physical and psychosocial well-being, and may have implications for health services utilisation. In the present paper, the authors outline the factors underpinning this sense of security, and argue that these findings contribute important new knowledge that is vital for contemporary debates about role responsibilities and continuity of care for cancer patients.     

Constructing a new role for family carers and volunteers providing care towards the end of life: an action research approach exploring a new model of hospice care

The objective of this study was to understand the conceptualisation and development of a novel way of providing end-of-life care in a Cottage Hospice setting, with a focus on the role of family carers and volunteers within this care model. A participatory action research design enabled a situational analysis, together with change processes. The study setting was a hospice in the South of England, and its network of wider associates in the local health economy. Participants were purposively sampled to provide relevant information. Data collection (2017–2018) included documents (e.g., meeting minutes) and interviews (individual and group) with external (e.g., GPs) and internal (e.g., staff, managers, volunteers, patients, family carers) stakeholders. These were followed by action cycles conducted by a core action group which explored issues related to family and young carers, the relationship between the main and Cottage Hospices and workforce engagement with the change process. Iterative, inductive, thematic analysis was followed by axial coding facilitated within NVivo. Twenty-six individual and eight follow-up interviews, two group interviews and five discrete action cycles were completed. At the core was a focus on disruption of the norm of professionally provided and mediated care, with three main themes: imagining the future of Cottage Hospice (growing demand, a home-like space, innovative roles for families and volunteers); developing the role of family caregivers (making agreements, meeting needs, social inclusion and the ‘unknown’ expectations) and quality and safety issues (negative perceptions, personalised care and volunteer roles). Change was viewed as both a threat and an opportunity. Cottage Hospice represents the possibility of a truly new way of meeting the needs of dying people and their families, and could act as a template for progressive service developments elsewhere.     

Internet-based risk assessment and decision support for the management of familial cancer in primary care: a survey of GPs' attitudes and intentions

BACKGROUND: Computer decision support systems have been proposed as a suitable method to enable primary care practitioners to manage familial cancer and advise about other developments in clinical genetics. OBJECTIVE: To investigate GPs' preferences, attitudes and intentions regarding the use of Genetic Risk Assessment on the Internet and Decision Support (GRAIDS) in clinical practice. METHODS: GPs were recruited through a physician Internet portal for UK GPs (www.ukpractice.net). Electronic questionnaires assessed the respondents' current practice regarding family history taking and risk assessment, preferences about particular attributes of GRAIDS, intentions to use GRAIDS for familial cancer management and factors associated with these intentions. RESULTS: Two hundred and sixty-eight GPs completed the electronic survey (adjusted response rate = 51.2%). Seventy-two GPs participated in a telephone survey of non-respondents (adjusted response rate = 63%). Ninety-two per cent of respondents in the electronic survey and 68% in the telephone survey stated that they would be either extremely or fairly likely to use GRAIDS. Intentions were associated with positive attitudes toward GRAIDS, beliefs that colleagues and patients would find the tool acceptable, perceived control and perceived confidence about conducting risk assessment and making appropriate decisions about patient management. Key attributes for the implementation of GRAIDS in practice were the authoritativeness of the guideline, easy user interface, the validity and reliability of risk estimation and specific advice about patient management. CONCLUSION: GP users of the physician portal www.ukpractice.net value GRAIDS as an aid for the management of familial cancer in primary care. These Internet-literate GPs are likely to be early adopters of GRAIDS in clinical practice and could be important in promoting the use of such technology to support high quality advice about genetic issues in primary care.     

Nurse practitioners in primary care

OBJECTIVES: Recent policy emphasizing the role of primary care has increased the workload of general practitioners (GPs) while simultaneously placing nurse practitioners (NPs) as key providers in the delivery of health care. There is need to examine the latter's work practices. The purpose of this article is to explore the role and practice of NPs in general practice. METHODS: DESIGN: Thirty-six semi-structured interviews with GPs, NPs, receptionists and patients were analysed. SETTING: Four general practices in south-east England. MAIN OUTCOME MEASURES: Data from semi-structured interviews relating to allocation, prescribing and referral practices of NPs in primary care. RESULTS: These include the differences in presenting problems of patients seen by GPs and NPs, prescribing and referral practice and legal issues of the nurse practitioner. A wide range of practice is reported. CONCLUSION: This study highlights the variation in how patients are allocated for NP consultation and in NP autonomy, prescribing and referral, which raises issues for clinical governance of protocols and risk management.     

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.