Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study

Background

Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.

Aim

To explore GPs'' views on the fit note, with particular reference to sickness certification for patients with chronic pain.

Design and setting

Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.

Method

In-depth interviews with 13 GPs.

Results

GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor–patient relationships, inconsistent engagement from employers, GPs'' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.

Conclusion

While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.     

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.     

Assessing physical activity in general practice: a disconnect between clinical practice and public health?

Background

GPs comply poorly to public health recommendations to routinely assess their patients'' physical activity. The reasons for this disconnect between recommended practice and GPs'' actual practice are unclear.

Aim

To investigate GPs'' perceptions of assessing physical activity, and to explore how GPs assess their patients'' physical activity.

Design of the study

Qualitative study.

Setting

General practice.

Method

Semi-structured interviews were performed with 15 randomly selected southern Tasmanian GPs, with stratification to include GPs with a range of demographic characteristics. Each interview was recorded, transcribed in full, and analysed using an iterative thematic approach to identify major themes.

Results

GPs recognised the importance of assessing physical activity, but rather than assessing every patient, they target at-risk patients and those with conditions likely to benefit from increased physical activity. Depth of assessment and GPs'' definition of sufficient physical activity varied according to the clinical and social context of each patient. Major barriers were the time needed to perform an adequate assessment and lack of time to deal with physical inactivity in patients once it was identified.

Conclusion

GPs'' assessment of physical activity is a complex and highly individualised process that cannot be divorced from the issue of managing physical inactivity once it is identified. Expectations that GPs will assess physical activity levels in all their patients are unlikely to be met. This must be taken into account when developing strategies to improve physical activity assessment in general practice, and should be considered in policy decisions about approaches to take to improve physical activity levels at a population level.     

Decisions about referrals for psychological therapies: a matched-patient qualitative study

Background

Psychological therapies are effective treatments for common mental health problems, but access is limited. GPs face difficult decisions as to whom to refer, but little is known about this decision-making process.

Aim

To explore GPs'' accounts of decisions to refer, or not refer, patients for psychological therapy.

Design of study

A qualitative study, using a matched-patient procedure.

Setting

General practices in two inner London boroughs.

Method

In semi-structured interviews, GPs were asked to compare and contrast five matched-patient pairs, consisting of patients who had been referred for psychological therapy paired with patients not referred. The interviews were analysed using a general thematic analysis.

Results

Fourteen GPs discussed 130 matched patients (65 patient pairs). Three main factors distinguished GPs'' accounts of the patients they referred compared with the matched patients they did not refer. These factors were: patient initiative in requesting or showing interest in referral; estimated capacity of the patient to benefit from psychological therapy; and the GP''s own capacity to help the patient in terms of skills, expertise, and time.

Conclusion

GPs gave accounts of themselves acting as rational decision makers, judging how effective they thought a referral would be based on a patient''s clinical presentation and motivation, compared with the GPs'' own ability to help.     

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.     

Factors influencing European GPs' engagement in smoking cessation: a multi-country literature review

Background

Smoking cessation advice by GPs is an effective and cost-effective intervention, but is not implemented as widely as it could be.

Aim

This wide-ranging Europe-wide literature review, part of the European Union (EU) PESCE (General Practitioners and the Economics of Smoking Cessation in Europe) project, explored the extent of GPs'' engagement in smoking cessation and the factors that influence their engagement.

Method

Two searches were conducted, one for grey literature, across all European countries, and one for academic studies. Data from eligible studies published from 1990 onwards were synthesised and reported under four categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills.

Results

The literature showed that most GPs in Europe question the smoking status of all new patients but fewer routinely ask this of regular patients, or advise smokers to quit. The proportion offering intensive interventions or prescribing treatments is lower still. Factors influencing GPs'' engagement in smoking cessation include GPs'' own smoking status and their attitudes towards giving smoking cessation advice; whether patients present with smoking-related symptoms, are pregnant, or heavy smokers; time, training, and reimbursement are important structural factors; and some GPs lack knowledge and skills regarding the use of specific cessation methods and treatments, or have limited awareness of specialist cessation services. No single factor or category of factors explains the variations in GPs'' engagement in smoking cessation.

Conclusion

Strategies to improve the frequency and quality of GPs'' engagement in smoking cessation need to address the multifaceted influences on GPs'' practice and to reflect the widely differing contexts across Europe.     

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.     

Questionnaire severity measures for depression: a threat to the doctor–patient relationship?

Background

Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.

Aim

To gain understanding of GPs'' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.

Design of study

Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.

Setting

Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.

Method

GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.

Results

Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs'' identities as professionals with expertise, constructed as integral to the process of diagnosis.

Conclusion

GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.     

Working towards a ‘fit note’: an experimental vignette survey of GPs

Background

The Department for Work and Pensions (DWP) has designed a trial medical statement.

Aim

To compare fitness for work assessment outcomes and written advice across current and trial medical statements. To examine the use of and suggestions to improve the trial medical statement.

Design of study

Comparative study with a two-way mixed design using questionnaire-based vignettes presenting GPs with three hypothetical sick leave cases (back pain, depression, combined back pain and depression) and medical statements (current or trial). The questionnaire also gathered GP views of using the trial Med 3.

Setting

Nine primary care organisations (PCOs) in England, Scotland, and Wales.

Method

Five hundred and eighty-three GPs employed in PCOs in summer 2008 were randomised to receive a current or trial Med 3 postal questionnaire. GPs assessed vignette patients'' fitness for work using the questionnaire medical statements.

Results

GPs using the trial Med 3 were less likely to advise refraining from work and more likely to provide written fitness for work advice compared to GPs using the current Med 3 form. Date sections of the trial Med 3 were used inconsistently, and a return to work date was unclear. GPs wanted further clarification of the implications of assessing a case as ‘fit for some work’ and its relationship to employers'' willingness to follow GP advice about work.

Conclusion

The study indicates a revised form may reduce the number of patients advised to refrain from work and increase the provision of written fitness for work information.     

GPs and involuntary admission: a qualitative study

Background

In many countries, medical authorities are responsible for involuntary admissions of mentally ill patients. Nonetheless, very little is known about GPs'' experiences with involuntary admission.

Aim

The aim of the present study was to explore GP''s experiences from participating in involuntary admissions.

Setting

General practice, Aarhus, Denmark.

Method

One focus group interview and six individual interviews were conducted with 13 Danish GPs, who had recently sectioned one of their own patients.

Results

GPs experienced stress and found the admission procedure time consuming. They felt that sectioning patients was unpleasant, and felt nervous, but experienced relief and professional satisfaction if things went well. The GPs experienced the doctor–patient relationship to be at risk, but also reported that it could be improved. GPs felt that they were not taken seriously by the psychiatric system.

Conclusion

The unpleasant experiences and induced feelings resulting from involuntary admissions reflect an undesirable and stressful working environment.     

Factors associated with prevalence and types of ‘may be fit’ advice on fit notes: a cross-sectional primary care analysis

Background

The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.

Aim

To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.

Design and setting

Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.

Method

Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.

Results

The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.

Conclusion

Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers).     

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.     

GPs' views in five European countries of interventions to promote prudent antibiotic use

Background

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

Aim

To explore GPs'' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

Design and setting

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

Method

Fifty-two semi-structured interviews explored GPs'' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

Results

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

Conclusion

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.     

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs' experiences

Background

Timely antenatal sickle cell and thalassaemia (SC&T) screening for all women in primary care facilitates informed decision making, but little is known about its implementation.

Aim

To assess the feasibility of offering antenatal SC&T screening in primary care at the time of pregnancy confirmation.

Design of study

Cross-sectional investigation of GPs'' beliefs and perceived practices.

Method

Informal face-to-face interviews with 34 GPs.

Setting

Seventeen inner-city general practices that offered antenatal SC&T screening as part of a trial.

Results

GPs identified both barriers and facilitators. Organisational barriers included inflexible appointment systems and lack of interpreters for women whose first language was not English. Professional barriers included concerns about raising possible adverse outcomes in the first antenatal visit. Perceived patient barriers included women''s lack of awareness of SC&T. Hence, GPs presented the test to women as routine, rather than as a choice. Organisational facilitators included simple and flexible systems for offering screening in primary care, practice cohesion, and training. Professional facilitators included positive attitudes to screening for SC&T. Perceived patient facilitators included women''s desire for healthy children.

Conclusion

GPs reported barriers, as well as facilitators, to successful implementation but the extent to which screening could be regarded as offering ‘informed choice’ remained fundamental when making sense of these barriers and facilitators.     

What happens when doctors are patients? Qualitative study of GPs

Background

Current evidence about the experiences of doctors who are unwell is limited to poor quality data.

Aim

To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.

Design of study

Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.

Setting

Two primary care trusts in the West of England.

Method

A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis

Results

Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.

Conclusion

Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.