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1.  The Quality and Outcomes Framework and self-management dialogue in primary care consultations: a qualitative study 
The British Journal of General Practice  2011;61(591):e666-e673.
Background
Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood.
Aim
To explore the use of computer-based ‘disease management’ templates and their relevance to self-management dialogue within clinical encounters.
Design and setting
Qualitative study of general practices located in three primary care trusts in the north of England.
Method
A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17).
Results
The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas.
Conclusion
In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.
doi:10.3399/bjgp11X601389
PMCID: PMC3177136  PMID: 22152849
consultation; chronic disease; doctor-patient relations; primary care; self-management
2.  Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access? 
BACKGROUND: Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. AIM: To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. DESIGN OF STUDY: A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. SETTING: Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. METHOD: Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. RESULTS: The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. CONCLUSION: A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.
PMCID: PMC1314467  PMID: 12528583
3.  A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance. 
BACKGROUND: It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices. AIMS: To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture. DESIGN: Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence. SETTING: Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England. RESULTS: Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice. CONCLUSIONS: The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.
PMCID: PMC1314382  PMID: 12171222
4.  The journey from self-care to GP care: a qualitative interview study of women presenting with symptoms of urinary tract infection 
The British Journal of General Practice  2009;59(564):e219-e225.
Background
Urinary tract infection (UTI) is one of the commonest acute infections presenting to primary care. Little is known of women's experiences of UTI; self-care strategies and key triggers for their consulting behaviour are also little known.
Aim
To explore women's experiences of self-care and their journey to GP care, when faced with symptoms of a UTI.
Design of study
Qualitative semi-structured interview study with women recruited to a larger UK trial of different management strategies for UTI.
Setting
General practices across four counties in southern England.
Method
Twenty-one women were interviewed about the experiences they had prior to their GP visit, self-care strategies, and triggers for help seeking. Interviews were analysed thematically, using principles of analytic induction.
Results
Women reported a process of evaluation, monitoring, re-evaluation, and, finally, consulting in order to meet their needs. Four key triggers for consulting were identified: failure to alleviate symptoms through self-care; symptom duration and escalation; impeding normal functioning and the fulfilment of social roles; and concern that it may be or become a serious illness.
Conclusion
Although UTI is often self-limiting, when taking patient histories and formulating their management strategies clinicians need to take into account women's often painful experience, their efforts to resolve symptoms prior to consulting, and their fears that the symptoms may indicate something more serious than a UTI.
doi:10.3399/bjgp09X453459
PMCID: PMC2702035  PMID: 19566988
antibiotics; consultation; urinary tract infection
5.  Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial 
Objective To determine the effectiveness of an intervention to enhance self management support for patients with chronic conditions in UK primary care.
Design Pragmatic, two arm, cluster randomised controlled trial.
Setting General practices, serving a population in northwest England with high levels of deprivation.
Participants 5599 patients with a diagnosis of diabetes (n=2546), chronic obstructive pulmonary disease (n=1634), and irritable bowel syndrome (n=1419) from 43 practices (19 intervention and 22 control practices).
Intervention Practice level training in a whole systems approach to self management support. Practices were trained to use a range of resources: a tool to assess the support needs of patients, guidebooks on self management, and a web based directory of local self management resources. Training facilitators were employed by the health management organisation.
Main outcome measures Primary outcomes were shared decision making, self efficacy, and generic health related quality of life measured at 12 months. Secondary outcomes were general health, social or role limitations, energy and vitality, psychological wellbeing, self care activity, and enablement.
Results We randomised 44 practices and recruited 5599 patients, representing 43% of the eligible population on the practice lists. 4533 patients (81.0%) completed the six month follow-up and 4076 (72.8%) the 12 month follow-up. No statistically significant differences were found between patients attending trained practices and those attending control practices on any of the primary or secondary outcomes. All effect size estimates were well below the prespecified threshold of clinically important difference.
Conclusions An intervention to enhance self management support in routine primary care did not add noticeable value to existing care for long term conditions. The active components required for effective self management support need to be better understood, both within primary care and in patients’ everyday lives.
Trial registration Current Controlled Trials ISRCTN90940049.
doi:10.1136/bmj.f2882
PMCID: PMC3652644  PMID: 23670660
6.  Is chronic pelvic pain a comfortable diagnosis for primary care practitioners: a qualitative study 
BMC Family Practice  2010;11:7.
Background
Chronic pelvic pain (CPP) has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs) and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain.
Methods
Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis.
Results
Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS). GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing.
Conclusions
The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS.
doi:10.1186/1471-2296-11-7
PMCID: PMC2835666  PMID: 20105323
7.  Patient safety culture in primary care: developing a theoretical framework for practical use 
Quality & Safety in Health Care  2007;16(4):313-320.
Objective
Great importance has been attached to a culture of safe practice in healthcare organisations, but it has proved difficult to engage frontline staff with this complex concept. The present study aimed to develop and test a framework for making the concept of safety culture meaningful and accessible to managers and frontline staff, and facilitating discussion of ways to improve team/organisational safety culture.
Setting
Eight primary care trusts and a sample of their associated general practices in north west England.
Methods
In phase 1 a comprehensive review of the literature and a postal survey of experts helped identify the key dimensions of safety culture in primary care. Semistructured interviews with 30 clinicians and managers explored the application of these dimensions to an established theory of organisational maturity. In phase 2 the face validity and utility of the framework was assessed in 33 interviews and 14 focus groups.
Results
Nine dimensions were identified through which safety culture is expressed in primary care organisations. Organisational descriptions were developed for how these dimensions might be characterised at five levels of organisational maturity. The resulting framework conceptualises patient safety culture as multidimensional and dynamic, and seems to have a high level of face validity and utility within primary care. It aids clinicians' and managers' understanding of the concept of safety culture and promotes discussion within teams about their safety culture maturity.
Conclusions
The framework moves the agenda on from rhetoric about the importance of safety culture to a way of understanding why and how the shared values of staff working within a healthcare organisation may be operationalised to create a safe environment for patient care.
doi:10.1136/qshc.2006.018366
PMCID: PMC2464946  PMID: 17693682
8.  Reactions to the use of evidence-based performance indicators in primary care: a qualitative study 
Quality in Health Care : QHC  2000;9(3):166-174.
Objectives—To investigate reactions to the use of evidence-based cardiovascular and stroke performance indicators within one primary care group.
Design—Qualitative analysis of semi-structured interviews.
Setting—Fifteen practices from a primary care group in southern England.
Participants—Fifty two primary health care professionals including 29 general practitioners, 11 practice managers, and 12 practice nurses.
Main outcome measures—Participants' perceptions towards and actions made in response to these indicators. The barriers and facilitators in using these indicators to change practice.
Results—Barriers to the use of the indicators were their data quality and their technical specifications, including definitions of diseases such as heart failure and the threshold for interventions such as blood pressure control. Nevertheless, the indicators were sufficiently credible to prompt most of those in primary care teams to reflect on some aspect of their performance. The most common response was to improve data quality through increased or improved accuracy of recording. There was a lack of a coordinated team approach to decision making. Primary care teams placed little importance on the potential for performance indicators to identify and address inequalities in services between practices. The most common barrier to change was a lack of time and resources to act upon indicators.
Conclusion—For the effective implementation of national performance indicators there are many barriers to overcome at individual, practice, and primary care group levels. Additional training and resources are required for improvements in data quality and collection, further education of all members of primary care teams, and measures to foster organisational development within practices. Unless these barriers are addressed, performance indicators could initially increase apparent variation between practices.
Key Words: performance indicators; primary care; primary care groups; training
doi:10.1136/qhc.9.3.166
PMCID: PMC1743530  PMID: 10980077
9.  Improving continence services for older people from the service-providers’ perspective: a qualitative interview study 
BMJ Open  2013;3(7):e002926.
Objective
To examine in depth the views and experiences of continence service leads in England on key service and continence management characteristics in order to identify and to improve our understanding of barriers to a good-quality service and potential facilitators to develop and to improve services for older people with urinary incontinence (UI).
Design
Qualitative semistructured interviews using a purposive sample recruited across 16 continence services.
Setting
3 acute and 13 primary care National Health Service Trusts in England.
Participants
16 continence service leads in England actively treating and managing older people with UI.
Results
In terms of barriers to a good-quality service, participants highlighted a failure on the part of commissioners, managers and other health professionals in recognising the problem of UI and in acknowledging the importance of continence for older people and prevalent negative attitudes towards continence and older people. Patient assessment and continence promotion regardless of age, rather than pad provision, were identified as important steps for a good-quality service for older people with UI. More rapid and appropriate patient referral pathways, investment in service capacity, for example, more trained staff and strengthened interservice collaborations and a higher profile within medical and nurse training were specified as being important facilitators for delivering an equitable and high-quality continence service. There is a need, however, to consider the accounts given by our participants as perhaps serving the interests of their professional group within the context of interprofessional work.
Conclusions
Our data point to important barriers and facilitators of a good-quality service for older people with UI, from the perspective of continence service leads. Further research should address the views of other stakeholders, and explore options for the empirical evaluation of the effectiveness of identified service facilitators.
doi:10.1136/bmjopen-2013-002926
PMCID: PMC3731733  PMID: 23901026
Geriatric Medicine
10.  Self-care in people with long term health problems: a community based survey 
BMC Family Practice  2011;12:53.
Background
Self-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine).
Methods
The study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only.
Results
Of the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care.
Conclusions
This study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.
doi:10.1186/1471-2296-12-53
PMCID: PMC3143929  PMID: 21689455
11.  Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views 
BMJ Open  2014;4(6):e004820.
Objectives
In the UK, there have been a number of national initiatives to promote earlier detection and prompt referral of patients presenting to primary care with signs and symptoms of cancer. The aim of the study was to explore the experiences of a range of primary care staff in promoting earlier presentation, detection and referral of patients with symptoms suggestive of cancer.
Setting
Six primary care practices in northwest England. Participants: 39 primary care staff from a variety of disciplines took part in five group and four individual interviews.
Results
The global theme to emerge from the interviews was ‘managing risk’, which had three underpinning organising themes: ‘complexity’, relating to uncertainty of cancer diagnoses, service fragmentation and plethora of guidelines; ‘continuity’, relating to relationships between practice staff and their patients and between primary and secondary care; ‘conflict’ relating to policy drivers and staff role boundaries. A key concern of staff was that policymakers and those implementing cancer initiatives did not fully understand how risk was managed within primary care.
Conclusions
Primary care staff expressed a range of views and opinions on the benefits of cancer initiatives. National initiatives did not appear to wholly resolve issues in managing risk for all practitioners. Staff were concerned about the number of guidelines and priorities they were expected to implement. These issues need to be considered by policymakers when developing and implementing new initiatives.
doi:10.1136/bmjopen-2014-004820
PMCID: PMC4067858  PMID: 24928585
QUALITATIVE RESEARCH; PUBLIC HEALTH
12.  The work of commissioning: a multisite case study of healthcare commissioning in England's NHS 
BMJ Open  2013;3(9):e003341.
Objective
To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.
Design
Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.
Participants
Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.
Setting
Three ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.
Results
Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.
Conclusions
Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
doi:10.1136/bmjopen-2013-003341
PMCID: PMC3773628  PMID: 24014483
Health Services Administration & Management; Qualitative Research
13.  Physician perceptions of primary prevention: qualitative base for the conceptual shaping of a practice intervention tool 
BMC Public Health  2002;2:16.
Background
A practice intervention must have its basis in an understanding of the physician and practice to secure its benefit and relevancy. We used a formative process to characterize primary care physician attitudes, needs, and practice obstacles regarding primary prevention. The characterization will provide the conceptual framework for the development of a practice tool to facilitate routine delivery of primary preventive care.
Methods
A focus group of primary care physician Opinion Leaders was audio-taped, transcribed, and qualitatively analyzed to identify emergent themes that described physicians' perceptions of prevention in daily practice.
Results
The conceptual worth of primary prevention, including behavioral counseling, was high, but its practice was significantly countered by the predominant clinical emphasis on and rewards for secondary care. In addition, lack of health behavior training, perceived low self-efficacy, and patient resistance to change were key deterrents to primary prevention delivery. Also, the preventive focus in primary care is not on cancer, but on predominant chronic nonmalignant conditions.
Conclusions
The success of the future practice tool will be largely dependent on its ability to "fit" primary prevention into the clinical culture of diagnoses and treatment sustained by physicians, patients, and payers. The tool's message output must be formatted to facilitate physician delivery of patient-tailored behavioral counseling in an accurate, confident, and efficacious manner. Also, the tool's health behavior messages should be behavior-specific, not disease-specific, to draw on shared risk behaviors of numerous diseases and increase the likelihood of perceived salience and utility of the tool in primary care.
doi:10.1186/1471-2458-2-16
PMCID: PMC126210  PMID: 12204096
14.  Leadership of healthcare commissioning networks in England: a mixed-methods study on clinical commissioning groups 
BMJ Open  2013;3(2):e002112.
Objective
To explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation.
Design
Mixed-method, multisite and case study research.
Setting
Six clinical commissioning groups and local clusters in the East of England area, covering in total 208 GPs and 1 662 000 population.
Methods
Semistructured interviews with 56 lead GPs, practice managers and staff from the local health authorities (primary care trusts, PCT) as well as various healthcare professionals; 21 observations of clinical commissioning group (CCG) board and executive meetings; electronic survey of 58 CCG board members (these included GPs, practice managers, PCT employees, nurses and patient representatives) and subsequent social network analysis.
Main outcome measures
Collaborative relationships between CCG board members and stakeholders from their healthcare network; clarifying the role of GPs as network leaders; strengths and areas for development of CCGs.
Results
Drawing upon innovation network theory provides unique insights of the CCG leaders’ activities in establishing best practices and introducing new clinical pathways. In this context we identified three network leadership roles: managing knowledge flows, managing network coherence and managing network stability. Knowledge sharing and effective collaboration among GPs enable network stability and the alignment of CCG objectives with those of the wider health system (network coherence). Even though activities varied between commissioning groups, collaborative initiatives were common. However, there was significant variation among CCGs around the level of engagement with providers, patients and local authorities. Locality (sub) groups played an important role because they linked commissioning decisions with patient needs and brought the leaders closer to frontline stakeholders.
Conclusions
With the new commissioning arrangements, the leaders should seek to move away from dyadic and transactional relationships to a network structure, thereby emphasising on the emerging relational focus of their roles. Managing knowledge mobility, healthcare network coherence and network stability are the three clinical leadership processes that CCG leaders need to consider in coordinating their network and facilitating the development of good clinical commissioning decisions, best practices and innovative services. To successfully manage these processes, CCG leaders need to leverage the relational capabilities of their network as well as their clinical expertise to establish appropriate collaborations that may improve the healthcare services in England. Lack of local GP engagement adds uncertainty to the system and increases the risk of commissioning decisions being irrelevant and inefficient from patient and provider perspectives.
doi:10.1136/bmjopen-2012-002112
PMCID: PMC3586053  PMID: 23430596
Health Services Administration & Management; Qualitative Research
15.  The compatibility of prescribing guidelines and the doctor-patient partnership: a primary care mixed-methods study 
The British Journal of General Practice  2012;62(597):e275-e281.
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.
doi:10.3399/bjgp12X636119
PMCID: PMC3310034  PMID: 22520915
decision making; evidence-based practice; patient compliance; physician-patient relations; professional practice
16.  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.
doi:10.3399/bjgp08X279760
PMCID: PMC2277111  PMID: 18387229
communication; interdisciplinary health care team; interprofessional relationships; primary care; palliative care
17.  Avoiding inappropriate paediatric admission: facilitating General Practitioner referral to Community Children’s Nursing Teams 
BMC Family Practice  2013;14:4.
Background
Children’s emergency admissions in England are increasing. Community Children’s Nursing Teams (CCNTs) have developed services to manage acutely ill children at home to reduce demand for unscheduled care. Referral between General Practitioners (GPs) and CCNTs may reduce avoidable admissions and minimise the psychosocial and financial impact of hospitalisation on children, families and the NHS. However, facilitators of GP referral to CCNTs are not known. The aim of this study was to identify facilitators of GP referral to CCNTs.
Methods
Semi-structured interviews with 39 health professionals were conducted between June 2009 and February 2010 in three Primary Care Trusts served by CCNTs in North West England. Interviewees included GPs, Community Children’s Nurses (CCNs), consultant paediatricians, commissioners, and service managers. Qualitative data were analysed thematically using the Framework approach in NVivo 8.
Results
Five facilitators were identified: 1) CCN/CCNT visibility; 2) clear clinical governance procedures; 3) financial and organisational investment in the role of CCNTs in acute care pathways; 4) access and out of hours availability; 5) facilitative financial frameworks.
Conclusion
GPs required confidence in CCNs’ competence to safely manage acutely ill children at home and secure rapid referral if a child’s condition deteriorated. Incremental approaches to developing GP referral to CCNTs underpinned by clear clinical governance protocols are likely to be most effective in building GP confidence and avoiding inappropriate admission.
doi:10.1186/1471-2296-14-4
PMCID: PMC3558326  PMID: 23289981
18.  Challenges to the credibility of patient feedback in primary healthcare settings: a qualitative study 
The British Journal of General Practice  2013;63(608):e200-e208.
Background
The UK government has encouraged NHS services to obtain patient feedback to support the further development of patient-centred care. In 2009, the English GP Patient Survey included a sample of 5.5 million, but little is known about its potential utility in informing developments aimed at improving the quality of patients’ experiences of primary care.
Aim
To investigate primary care providers’ response to feedback on patient experience from a national survey.
Design and setting
Qualitative interview study in 10 general practices from four primary care trusts in England.
Method
Semi-structured interviews were conducted with GPs, practice nurses, and practice managers (n = 37). Transcripts were analysed thematically.
Results
Although some participants reported making changes to their practice in response to the survey data, many expressed doubts about the credibility of the results. Key issues included: concerns about practical aspects of the survey, such as the response rate and representativeness of the sample; the view that it gave insufficient detail to facilitate change and failed to address some salient issues; and unease about the influence of political influences underpinning its introduction and use.
Conclusion
Although, in general, primary care professionals have positive attitudes towards patient feedback, this study suggests a mismatch between the conventional demonstration of the objectivity of a questionnaire survey and the attitudes and experiences of those receiving the data. This is likely to prevent doctors from engaging constructively with the survey. These concerns may well militate against the potential of the survey to act as a simple means of capturing, and effectively using, feedback from patients.
doi:10.3399/bjgp13X664252
PMCID: PMC3582979  PMID: 23561787
primary healthcare; qualitative research; reliability and validity; surveys
19.  Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons: A Norwegian Qualitative Implementation Study 
Nursing Research and Practice  2013;2013:794743.
In order to deliver effective care, it is necessary to organise interdisciplinary activities for older persons who suffer from depressive disorders. This paper evaluated the interdisciplinary team members' perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM). A qualitative implementation design was used, data were collected by means of multistage focus groups, and a thematic analysis was performed. Three themes emerged: lack of effective team leadership in the community, the need to change the delivery system, and enhancing self-management support for depressed older persons as well as the participation of their families. It was concluded that nurse managers must find ways of supporting the depressed older persons by better structuring the care, increasing cooperation with organisational leadership, and creating an environment characterised by trust and mutual respect. Distrust can have serious implications for discharge planning collaboration. The development of a common vision of transparency in the organization is important as is a policy of change among leadership and in clinical practice.
doi:10.1155/2013/794743
PMCID: PMC3671551  PMID: 23766896
20.  Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study 
The British Journal of General Practice  2012;62(597):e233-e242.
Background
Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.
Aim
To explore processes underpinning the implementation of CKD management in primary care.
Design and setting
Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.
Method
Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.
Results
A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.
Conclusion
Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.
doi:10.3399/bjgp12X636056
PMCID: PMC3310029  PMID: 22520910
doctor–patient relations; kidney disease; chronic; normalisation process theory; primary care
21.  Implementing the role of the primary care mental health worker: a qualitative study 
Background
Primary care mental health workers are a new role recently introduced into primary care in England to help manage patients with common mental health problems.
Aim
To explore the views of GPs, primary care teams and patients on the value and development of the new role of primary care mental health workers in practice.
Design of study
Qualitative study.
Setting
The Heart of Birmingham Primary Care Teaching Trust in the West Midlands, UK.
Method
Thirty-seven semi-structured interviews involving seven primary care mental health workers, 21 patients and 11 focus groups involving 38 members of primary care teams were held with six teams with a worker. Two teams asked for the worker to be removed. Six practice managers also took part in the study.
Results
A number of different approaches were used to implement this new role. Strategies that incorporated the views of primary care trust senior management, primary care teams and workers' views appeared most successful. Rapid access to a healthcare professional at times of stress and the befriending role of the worker were also highly valued. Workers felt that their role left them professionally isolated at times. A number of workers described tension around ownership of the role.
Conclusion
Primary care mental health workers appear to provide a range of skills valued by patients and the primary care teams and can increase patient access and choice in this area of health care. Successful implementation strategies highlighted in this study may be generalisable to other new roles in primary care.
PMCID: PMC2042560  PMID: 17359607
health personnel; mental health; primary health care; primary care mental health workers
22.  Patient Perspectives on Fluid Management in Chronic Hemodialysis 
Objective
To describe the perspectives and experiences of chronic hemodialysis (CHD) patients regarding self-care and adherence to fluid restrictions.
Design
Semi-structured focus groups.
Setting
Two outpatient hemodialysis centers.
Participants
19 patients on chronic hemodialysis.
Intervention
Patients were asked a series of open-ended questions to encourage discussion about the management of fluid restriction within the broad categories of general knowledge, knowledge sources or barriers, beliefs and attitudes, self-efficacy, emotion, and self-care skills.
Main outcome measure
We analyzed session transcripts using the theoretical framework of content analysis to identify themes generated by the patients.
Results
Patients discussed both facilitators and barriers to fluid restriction which we categorized into 6 themes: knowledge, self-assessment, psychological factors, social, physical, and environmental. Psychological factors were the most common barriers to fluid restriction adherence, predominantly involving lack of motivation. Knowledge was the most discussed facilitator with accurate self-assessment, positive psychological factors, and supportive social contacts also playing a role. Dialysis providers were most commonly described as the source of dialysis information (54%), but learning through personal experience was also frequently noted (28%).
Conclusion
Interventions to improve fluid restriction adherence of chronic hemodialysis patients should target motivational issues, assess and improve patient knowledge, augment social support, and facilitate accurate self-assessment of fluid status.
doi:10.1053/j.jrn.2009.09.001
PMCID: PMC2888683  PMID: 19913443
hemodialysis; interdialytic weight gain; focus group; quality of life; qualitative research
23.  Stepped care for depression is easy to recommend, but harder to implement: results of an explorative study within primary care in the Netherlands 
BMC Family Practice  2014;15:5.
Background
Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care.
Methods
Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire.
Results
Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs.
Conclusions
The management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.
doi:10.1186/1471-2296-15-5
PMCID: PMC3893377  PMID: 24400701
Qualitative research; Primary health care; General practice; Depression; Stepped care; Collaborative care
24.  Management of Chronic Hypertension in Older Men: An Exploration of Patient Goal-Setting 
Patient education and counseling  2007;69(1-3):93-99.
Objective
Despite the success of the collaborative care approach on chronic disease outcomes; many patients fail to adopt the behaviors necessary to manage their disease. Goal-setting is an approach to collaborative chronic care that involves the setting of goals for the activation and maintenance of specific self-care behaviors. Using patients' perspectives this study will describe how goals for the self-management of hypertension are developed and whether they conform to the characteristics of effective goal setting.
Methods
Qualitative methodology was used to explore the process of setting self-management goals for hypertensive patients. Thirty patients participated in semi-structured interviews based on the deductive framework of goal setting.
Results
Patients understand the risks associated with hypertension, have intentions to control their disease, report conducting at least one self-care task, and set informal goals for themselves; however these goals lack the characteristics needed to initiate and maintain behavior change.
Conclusion
goal setting is applicable to chronic hypertension care. Future studies need to examine ways to minimize barriers to effective goal setting to improve hypertension control.
Practice implications
as part of the process of chronic hypertension care, health care providers should include time and support for dedicated goal setting to improve the effectiveness of self-management behaviors.
doi:10.1016/j.pec.2007.07.006
PMCID: PMC2860531  PMID: 17890042
Hypertension; Goal Setting; Self-Management
25.  Patient self-monitoring of blood pressure and self-titration of medication in primary care: the TASMINH2 trial qualitative study of health professionals’ experiences 
The British Journal of General Practice  2013;63(611):e378-e385.
Background
Self-monitoring with self-titration of antihypertensives leads to reduced blood pressure. Patients are keen on self-monitoring but little is known about healthcare professional views.
Aim
To explore health professionals‘ views and experiences of patient self-management, particularly with respect to future implementation into routine care.
Design and setting
Qualitative study embedded within a randomised controlled trial of healthcare professionals participating in the TASMINH2 trial of patient self-monitoring with self-titration of antihypertensives from 24 West Midlands general practices.
Method
Taped and transcribed semi-structured interviews with 13 GPs, two practice nurses and one healthcare assistant. Constant comparative method of analysis.
Results
Primary care professionals were positive about self-monitoring, but procedures for ensuring patients measured blood pressure correctly were haphazard. GPs interpreted home readings variably, with many not making adjustment for lower home blood pressure. Interviewees were satisfied with patient training and arrangements for blood pressure monitoring and self-titration of medication during the trial, but less sure about future implementation into routine care. There was evidence of a need for training of both patients and professionals for successful integration of self-management.
Conclusion
Health professionals wanted more patient involvement in hypertension care but needed a framework to work within. Consideration of how to train patients to measure blood pressure and how home readings become part of their care is required before self-monitoring and self-titration can be implemented widely. As home monitoring becomes more widespread, the development of patient self-management, including self-titration of medication, should follow but this may take time to achieve.
doi:10.3399/bjgp13X668168
PMCID: PMC3662454  PMID: 23735408
general practice; hypertension, primary care; qualitative research, self-monitoring

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