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Background: Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections., Aim: The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists)., Design and Setting: Systematic review and meta-ethnography of qualitative studies., Method: A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed., Results: In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary)., Conclusion: Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities., (© British Journal of General Practice 2018.)

Background: People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated., Aim: To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment., Design and Setting: A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London., Method: A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes., Results: Acupuncture, initially accepted as 'just another referral' - one like many others that had been tried and proved unsuccessful - was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture., Conclusion: Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.

Background: Medically unexplained physical symptoms (MUPS) are common and difficult to treat., Aim: To investigate the effectiveness of adding five-element acupuncture to usual care in 'frequent attenders' with MUPS., Design and Setting: Randomised controlled trial in four London general practices., Method: Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes., Results: Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control -0.6 [95% CI = -1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = -0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to -0.4 (95% CI = -0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks., Conclusion: The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.

Background: Patients vary in their desire to be involved in decisions about their care., Aim: To assess the accuracy and impact of GPs' perceptions of their patients' desire for involvement., Design of Study: Consultation-based study., Setting: Five primary care centres in south London., Method: Consecutive patients completed decision-making preference questionnaires before and after consultation. Eighteen GPs completed a questionnaire at the beginning of the study and reported their perceptions of patients' preferences after each consultation. Patients' satisfaction was assessed using the Medical Interview Satisfaction Scale. Analyses were conducted in 190 patient-GP pairs that identified the same medicine decision about the same main health problem., Results: A total of 479 patients participated (75.7% of those approached). Thirty-nine per cent of these patients wanted their GPs to share the decision, 45% wanted the GP to be the main (28%) or only (17%) decision maker regarding their care, and 16% wanted to be the main (14%) or only (2%) decision maker themselves. GPs accurately assessed patients' preferences in 32% of the consultations studied, overestimated patients' preferences for involvement in 45%, and underestimated them in 23% of consultations studied. Factors protective against GPs underestimating patients' preferences were: patients preferring the GP to make the decision (odds ratio [OR] 0.2 per point on the five-point scale; 95% confidence interval [CI] = 0.1 to 0.4), and the patient having discussed their main health problem before (OR 0.3; 95% CI = 0.1 to 0.9). Patients' educational attainment was independently associated with GPs underestimation of preferences., Conclusion: GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when patients have not consulted about their condition before.

Background: Menstrual disorders are a common presentation in primary care. Wide variations in management as well as discordance between patient and practitioners in relation to presenting problems have been described., Aims: To explore the model of menstrual disorders used by practitioners in practice., Design of Study: Semi-structured interviews with primary care practitioners., Setting: One inner London health authority area., Method: Constant comparative analysis., Results: Medical practitioners were critical of the guidance provided by gynaecological definitions and texts. Practitioners put more emphasis on defining normality than on defining disorder. Practitioners used a wide range of criteria to judge their patients' complaints and decide on a course of action. Female practitioners had access to personal and professional experience and used this to develop an understanding of women's complaints. Male practitioners in particular were limited by problems in discussing menstruation in detail. Because of the difficulties in assessing patient history, other non-gynaecological factors such as patient age and consulting behaviour informed practitioners' judgements., Conclusion: This study draws attention to practitioners' problems in using current definitions of menstrual disorders. The combination of unhelpful medical definitions, lack of standards of normality and difficulties in discussing menstruation resulted in individual practitioners making judgements in idiosyncratic ways. In the absence of a useful gynaecological model, practitioners develop individual, often subjective and gendered models to use in practice.

Background: The 1993 chronic disease management contract encourages United Kingdom general practices to implement a standardised package of care with an emphasis on regular visits to an asthma clinic., Aim: To explore the views of people with asthma about the organisation of asthma care in general practice., Method: Semi-structured interviews with 20 patients registered with one practice with a nurse-run asthma clinic. The sample was selected to provide people with a wide range of ages and disease severity, and included parents of children., Results: The age range of the interviewees was five to 87 years (parents of children were interviewed) and half of the interviewees had attended the asthma clinic at some time. In describing how they managed their asthma, people identified their medical care alongside other important factors, such as avoiding smoking and pollution, and a decision to seek medical help was made in the context of all of life's other priorities. People expressed diverse views about the organisation of care, describing how their needs changed over time and how they balanced up several factors in deciding what was best for them. These factors were encompassed by four themes: the accessibility of care, severity of asthma and dealing with uncertainty, self-knowledge and self-management, and expert knowledge and therapeutic relationships. Interviewees were evenly split between wishing to be seen regularly in the clinic and wishing only to attend when needing help., Conclusion: Patients required asthma services that allow individual choice and flexibility, and eight service objectives were identified that would cover most people's needs.

Background: Although there is some published work acknowledging that the general practice receptionist's role is both important and difficult, receptionists' own views have rarely been sought., Aim: To explore general practice receptionists' ideas and feelings about their work., Method: A questionnaire was distributed to all 150 receptionists in a representative sample of 26 practices in the area covered by Leeds family health services authority. Semi-structured interviews were conducted with a representative group of 20 receptionists selected from the questionnaire sample., Results: All responders were women, 60% were over 40 years old, and about half had been in the post for more than five years; four-fifths worked part-time. They had chosen the job because it dovetailed with the rest of their lives. Responders derived satisfaction from helping patients, meeting people, having good relationships with colleagues, and doing varied work. Sources of stress included difficult patients, work pressure, problems finding appointments for patients, and feeling caught between doctors' and patients' demands. Responders' experiences and views of training were diverse. Practice managers were important in making them feel consulted and supported. All had a sense of teamwork with colleagues, but many did not perceive the whole practice as a team. Many felt doctors failed to appreciate the pressure and complexity of their work., Conclusions: Receptionists' work is complex, demanding and intense, involving a high level of commitment to patients, colleagues, and the practice. Recommendations include improved appointment systems, a positive role for practice managers in relation to reception staff, and individual planning of receptionists' training. Effective teamwork among receptionists should be recognized and developed. General practitioners (GPs) are recommended to develop a greater understanding of receptionists' work.

Background: The United Medical and Dental School's (UMDS's) MSc in general practice is one of the longest running courses of its kind. Although descriptive accounts of such courses have been published, little is known about their outcomes., Aim: To measure the extent to which graduates feel they have personally achieved 16 intended outcomes derived from the course objectives, and to record current academic activities, particularly teaching and research., Method: A postal questionnaire to graduates of the UMDS MSc in General Practice., Results: The response rate was 93%. Of the 71 responders, 23 have gone on to register for or complete other degrees or diplomas. Over two-thirds of responders had an academic commitment following the MSc. Two-thirds were currently engaged in research and over half reported having had work accepted for publication. The majority of graduates confirmed the attainment of all 16 outcomes, although outcomes related to personal achievements were endorsed more strongly than those related to service delivery., Conclusion: UMDS graduates are making a significant contribution to their discipline and are unanimous in describing the course as an important event in their personal development. As a result of this study, the course organizers are seeking to increase the links between academic study and everyday practice.

Background: A small number of studies have used different methodologies to measure primary non-compliance, but they have not established the reasons for patients not cashing their prescriptions. It has been suggested that the number of uncashed prescriptions is a measure of the quality of doctor-patient communication, but this hypothesis remains untested., Aim: To establish the feasibility of obtaining data on a sensitive subject from patients by interview and to seek patients' reasons for not cashing prescriptions using qualitative data., Method: Questionnaire administered to 1000 consecutive patients attending surgery, followed by interview with those patients who indicated that they had not cashed the index prescription., Results: The response rate was 93.5%. Twenty-two patients were included in the study. There was wide variation in the number of uncashed prescriptions issued by each doctor (1-13). A total of nine out of 22 patients reported that their medication was cheaper over the counter and obtained it in this way; 13 out of 22 did not obtain their medication. Five patients indicated that cost was a factor in not obtaining their medication. Other factors included the doctor's permission not to cash the prescription, poor understanding of the illness, and the wish to maintain control., Conclusion: It is feasible to ask patients about aspects of their behaviour that may indicate, or cause, difficulties in the doctor-patient relationship. Prescribing behaviour varies widely between doctors and, although cost is a factor in determining whether a prescription will be cashed, other variables, such as the patient's desire to maintain control over the illness, may be more important.

Background: In recent years there has been a trend towards increasing the number of drugs that are available over the counter (OTC) without prescription. Simultaneously, community pharmacists have been encouraged to develop and extend their role. General practitioners (GPs) have been shown to have some reservations about these developments. A group of drugs widely used in general practice, the H2-antagonists, have recently become available OTC., Aim: To examine GPs' attitudes towards community pharmacists dispensing H2-antagonists over the counter (OTC) without prescription., Method: Postal questionnaire to a sample of GPs from inner and outer London, Surrey, Kent, Hampshire, Northumberland, Newcastle upon Tyne and Leicestershire., Results: Of 850 questionnaires sent, 515 were returned, an overall response rate of 60.5%. Fifty four per cent of respondents agreed that cimetidine should be available over the counter for dyspepsia in adults under 45 years not responsive to antacids. Ninety per cent of respondents were aware that H2-antagonists had been deregulated. Most general practitioners learned about the deregulation from professional journals. Very few GPs stated they had changed their prescribing practice since H2-antagonists became available OTC. The high cost to the patient of the OTC product was the most frequently mentioned reason why respondents did not encourage their patients to switch from prescription to OTC H2-antagonists. Worries and concerns regarding the OTC availability of H2-antagonists included masking serious conditions, missed diagnosis, loss of control by the GP and the potential for inappropriate use by patients., Conclusions: Since 1990, there has been a large increase in GPs support for the OTC availability of cimetidine. However, according to their stated behaviour, the reclassification of H2-antagonists does not seem to have changed GPs' prescribing practice, and few appear to be recommending that their patients buy them over the counter.

Background: Research suggests that patients are more satisfied with patient-centred consultations than with doctor-centred consultations and that some health measures are positively influenced by this type of consultation. Research on the factors that influence the patient centredness of the consultation is sparse but suggests that women doctors are more patient centred than men doctors., Aim: A study was designed, first, to confirm or reject the suggestion that women general practitioners are more patient centred than men general practitioners and, secondly, to determine some of the factors that might influence the patient centredness of a general practitioner., Method: The audiotaped consultations of 41 general practitioners were analysed using an instrument designed to measure patient centredness. The general practitioners were selected from a group of volunteers to represent both sexes as well as a wide range of age and experience., Results: The results of the analysis showed that women general practitioners, particularly trainers, had higher patient-centredness scores than men general practitioners. This behaviour is characterized by an increased frequency of open questions and greater attention to patient offers (anything of potential significance that a patient brings to the general practitioner consultation). Additionally, the combination of sexes in a consultation seemed to have an effect on the interaction, with woman general practitioner/female patient dyads (pairings) having the highest median patient-centredness score, woman general practitioner/male patient and man general practitioner/male patient dyads scoring the same as each other and man general practitioner/female patient dyads having the lowest median scores., Conclusion: The results suggest that women general practitioners, in this sample, were more patient centred than men general practitioners. The results also suggest that inherent inequalities exist, with female patients receiving a more patient-centred service from general practitioners of their own sex than from general practitioners of the opposite sex. Male patients, on the other hand, seemed to fare equally well, irrespective of the sex of their general practitioner. Training is required to address these inequalities and to improve the level of patient centredness in the consultation.

Background: The development of modern information technology and the increasing amount of multidisciplinary teamwork in primary health care mean that the principle of patient confidentiality is becoming difficult to uphold. The debate about confidentiality so far has paid little attention to patients' views., Aim: A qualitative study was undertaken to explore patients' expectations and attitudes concerning confidentiality of patients' medical records in general practice., Method: Semi-structured interviews were carried out with 39 patients from one general practice., Results: Patients' expectations diverged considerably from actual practice. The majority of interviewees felt that administrative and secretarial staff should not have access to medical records. Some patients had reservations about a doctor not directly involved in their care having access to their records. They were unaware of the fact that practice staff had ready access to their medical records. Interviewees had particular concerns about recording of nonmedical information in their records, and the confidentiality of computerized records., Conclusion: Assumptions of shared doctor-patient definitions of confidentiality, at least in this practice, would be misplaced. It is suggested that explicit negotiations about what is recorded in patients' records would go some way to addressing the discrepancies identified in this study.

Background: Little attention has been paid to patients' ideas about medicines and such ideas might well have relevance for understanding non-adherence to medication., Aim: This qualitative study set out to describe the ideas about medicines and the self-reported adherence to medication of a general practice population., Method: Semistructured interviews were conducted with 30 adult patients (attenders and non-attenders) from two general practices., Results: The main themes emerging from the analysis were: perceived properties of medicines; orientation towards medicines, that is, patients' general preference for taking or not taking medication; and actual usage of medicines. The data revealed that on the one hand much medicine taking was taken for granted and on the other hand that patients had many fears and powerful negative images of medicines., Conclusion: Any assessment of the appropriateness of a proposed treatment for an individual patient should include an exploration of his or her preferences, orientation towards medicines and social context.

The aim of this study was to examine cancer patients' reactions to the offer of access to their medical records, hospital doctors' preconceptions of patient access to medical records and the reality of access to records for both parties. Semistructured interviews were conducted with 32 patients and 21 hospital doctors. Hospital doctors were also shown letters from their department to the general practitioner and asked about any changes they would have made as a result of knowing about patient access to records. The results showed that most patients were able to judge for themselves if they wanted access or not and that patients who chose to look at their records found access to their records helpful and reassuring even if the news was bad. Doctors expected access to records to be harmful to patients but would not have wished to amend many of the letters they had written. Patient access to records can be a safe and useful adjunct to good patient care.