Search

UK general practitioner (GP) trainees are taught a consultation model which elicits the patients' main reason for consulting 'today'. This approach will often miss important issues for the increasing number of patients with multimorbidity. We developed the SHERPA model as a person-centred biopsychosocial framework for consulting patients with multimorbidity to address this. We aimed to examine GPs trainees' responses to SHERPA when integrated into their vocational training. The research design was qualitative and participants were GPs trainees in vocational training from one UK training location. GP trainees were introduced to the SHERPA model through interactive workshops. Qualitative data were collected from 16 participants, through four hours of teaching observation, 24 feedback templates, six practical applications of SHERPA and eight one-to-one interviews. Data were transcribed, and, using the Framework approach, systematically analysed, focussing on trainees' learning and application of the model. The results demonstrated that all participants engaged well with the teaching sessions, brought observations from their own experience, and reflected on particularly complex consultations. Half of the participants applied SHERPA successfully with their patients, particularly repeat attenders. Barriers to this approach were: selecting appropriate patients; perceived time pressure; lack of familiarity using the model; viewing SHERPA as 'additional', rather than integral, to shared decision-making in complex situations. The SHERPA model was viewed as helpful by these GP trainees for patients with whom they had established a relationship. Earlier introduction and regular support from trainers, where trainees reflect on experience of SHERPA, could increase confidence in using this method.

Background: In the UK, general practitioners (GPs) are the most commonly used providers of care for emotional concerns., Objective: To update and synthesize literature on barriers and facilitators to GP-patient communication about emotional concerns in UK primary care., Design: Systematic review and qualitative synthesis., Method: We conducted a systematic search on MEDLINE (OvidSP), PsycInfo and EMBASE, supplemented by citation chasing. Eligible papers focused on how GPs and adult patients in the UK communicated about emotional concerns. Results were synthesized using thematic analysis., Results: Across 30 studies involving 342 GPs and 720 patients, four themes relating to barriers were: (i) emotional concerns are difficult to disclose; (ii) tension between understanding emotional concerns as a medical condition or arising from social stressors; (iii) unspoken assumptions about agency resulting in too little or too much involvement in decisions and (iv) providing limited care driven by little time. Three facilitative themes were: (v) a human connection improves identification of emotional concerns and is therapeutic; (vi) exploring, explaining and negotiating a shared understanding or guiding patients towards new understandings and (vii) upfront information provision and involvement manages expectations about recovery and improves engagement in treatment., Conclusion: The findings suggest that treatment guidelines should acknowledge: the therapeutic value of a positive GP-patient relationship; that diagnosis is a two-way negotiated process rather than an activity strictly in the doctor's domain of expertise; and the value of exploring and shaping new understandings about patients' emotional concerns and their management., (© The Author(s) 2020. Published by Oxford University Press.)

Background: NICE guidelines for the management of emotional concerns in primary care emphasise the importance of communication and a trusting relationship, which is difficult to operationalise in practice. Current pressures in the NHS mean that it is important to understand care from a patient perspective. This study aimed to explore patients' experiences of primary care consultations for emotional concerns and what patients valued when seeking care from their GP., Methods: Eighteen adults with experience of consulting a GP for emotional concerns participated in 4 focus groups. Data were analysed thematically., Results: (1) Doctor as Drug: Patients' relationship with their GP was considered therapeutic with continuity particularly valued. (2) Doctor as Detective and Validator: Patients were often puzzled by their symptoms, not recognising their emotional concerns. GPs needed to play the role of detective by exploring not just symptoms, but the person and their life circumstances. GPs were crucial in helping patients understand and validate their emotional concerns. (3) Doctor as Collaborator: Patients prefer a collaborative partnership, but often need to relinquish involvement because they are too unwell, or take a more active role because they feel GPs are ill-equipped or under too much pressure to help. Patients valued: GPs booking their follow up appointments; acknowledgement of stressful life circumstances; not relying solely on medication., Conclusions: Seeking help for emotional concerns is challenging due to stigma and unfamiliar symptoms. GPs can support disclosure and understanding of emotional concerns by fully exploring and validating patients' concerns, taking into account patients' life contexts. This process of exploration and validation forms the foundation of a curative, trusting GP-patient relationship. A trusting relationship, with an emphasis on empathy and understanding, can make patients more able to share involvement in their care with GPs. This process is cyclical, as patients feel that their GP is caring, interested, and treating them as a person, further strengthening their relationship. NICE guidance should acknowledge the importance of empathy and validation when building an effective GP-patient partnership, and the role this has in supporting patients' involvement in their care.

Up to 40% of general practitioners (GP) consultations contain an emotional component. General practitioners (GPs) have to provide care with limited time and resources. This qualitative study aimed to explore how GPs care for patients experiencing emotional concerns within the constraints of busy clinical practice. Seven GPs participated in three focus groups. Groups were recorded, transcribed and analysed thematically. Three themes were identified. (a) Collaboratively negotiated diagnosis: How patients' emotional concerns are understood and managed is the result of a negotiation between patient and GP belief models and the availability of treatments including talking therapy. (b) Doctor as drug: Not only is a continuous relationship between GPs and patients therapeutic in its own right, it is also necessary to effectively diagnose and engage patients in treatment as patients may experience stigma regarding emotional concerns. (c) Personal responsibility and institutional pressure: GPs feel personally responsible for supporting patients through their care journey, however, they face barriers due to lack of time and pressure from guidelines. GPs are forced to prioritise high-risk patients and experience an emotional toll. In conclusion, guidelines focus on diagnosis and a stepped-care model, however, this assumes diagnosis is relatively straightforward. GPs and patients have different models of psychological distress. This and the experience of stigma mean that establishing rapport is an important step before the GP and patient negotiate openly and develop a shared understanding of the problem. This takes time and emotional resources to do well. Longer consultations, continuity of care and formal supervision for GPs could enable them to better support patients., (© 2019 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Background: Offenders frequently have substantial healthcare needs and, like many other socially marginalised groups, often receive healthcare in inverse proportion to their needs. Improved continuity of healthcare over time could contribute to addressing these needs. General Practitioners need to be able to support people with complex social and medical problems, even in systems that are not specifically designed to manage individuals with such degrees of complexity. We aimed to examine offenders' perspectives on factors that contributed to, or worked against, creating and sustaining their access to healthcare., Methods: From a sample of 200 participants serving community or prison sentences in South West (SW) and South East (SE) England, who were interviewed about their health care experiences as part of the Care for Offenders: Continuity of Access (COCOA) study, we purposively sampled 22 participants for this sub-study, based on service use. These interviews were transcribed verbatim. A thematic analytic approach initially applied 5 a priori codes based on access and different components of continuity. Data were then examined for factors that contributed to achieving and disrupting access and continuity., Results: Participants described how their own life situations and behaviours contributed to their problems in accessing healthcare and also identified barriers created by existing access arrangements. They also highlighted how some General Practitioners used their initiative and skills to 'workaround' the system, and build positive relationships with them; feeling listened to and building trust were particularly valued, as was clear communication. Limitations faced by General Practitioners included a lack of appropriate services to refer people to, where the offender patients would meet the access criteria, and disagreements regarding medication prescriptions., Conclusions: General Practitioners can make a positive contribution to supporting access to healthcare for an under-served population by facilitating more flexible and less formal access arrangements, by using their relationship skills, and by problem-solving. General Practitioners should recognise their potential to transform people's experience of healthcare whilst working in imperfect systems, particularly with vulnerable and marginalised groups who have complex medical and social needs.

Existing research indicates that many patients and doctors find the process of negotiating sickness certification for time off work to be a difficult one. This study examined how patients and general practitioners (GPs) managed these negotiations in a sample of UK primary care consultations. The study made use of an existing dataset of audio-recorded consultations between 13 GPs and 506 unselected adult patients in five general practices in London. Forty-nine consultations included discussions for both initial and repeat sickness certification across a wide range of conditions. Here we report our findings on doctor practices for recommending, as opposed to patient practices for advocating for, sickness certification (n = 26 cases). All cases were transcribed in detail and analysed using conversation analytic methods. Four main communication practices were observed: (1) declarative statements of need for sickness certification; (2) 'do you need' offers for sickness certification; (3) 'do you want' offers for sickness certification; and (4) conditional 'If X, Y' offers for sickness certification. These different communication practices indexed doctor agency, doctor endorsement and patient entitlement to varying degrees. In the main, recommendations to patients presenting with biomedical problems or a repeat occurrence of a psychosocial problem displayed stronger doctor endorsement and patient entitlement. Contrastingly, recommendations to patients presenting with new psychosocial and biopsychosocial problems, displayed weaker endorsement and patient entitlement. This study offers new evidence to support the Parsonian argument that becoming sick involves entering a social role with special rights and obligations. Through documenting doctors' orientations to their gatekeeping role as well as patients' orientations to differential rights vis à vis legitimacy, we demonstrate the contrasting stances of doctors in situ when giving sick notes for biomedical problems as opposed to difficulties of a more psychosocial nature., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Intermediate care (IC) was redesigned to manage more complex, older patients in the community, avoid admissions and facilitate earlier hospital discharge. The service was 'enhanced' by employing GPs, pharmacists and the voluntary sector to be part of a daily interdisciplinary team meeting, working alongside social workers and community staff (the traditional model). Methods: A controlled before-and-after study, using mixed methods and a nested case study. Enhanced IC in one locality (Coastal) is compared with four other localities where IC was not enhanced until the following year (controls), using system-wide performance data (N = 4,048) together with ad hoc data collected on referral-type, staff inputs and patient experience (N = 72). Results: Coastal showed statistically significant increase in EIC referrals to 11.6% (95%CI: 10.8%--12.4%), with a growing proportion from GPs (2.9%, 95%CI: 2.5%-3.3%); more people being cared for at home (10.5%, 95%CI: 9.8%-11.2%), shorter episode lengths (9.0 days, CI 95%: 7.6-10.4 days) and lower bed-day rates in ≥70 yearolds (0.17, 95%CI: 0.179-0.161). The nested case study showed medical, pharmacist and voluntary sector input into cases, a more holistic, coordinated service focused on patient priorities and reduced acute hospital admissions (5.5%). Discussion and conclusion: Enhancing IC through greater acute, primary care and voluntary sector integration can lead to more complex, older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits. [ABSTRACT FROM AUTHOR]

Many patients with depression do not recover despite medication or therapy. Individuals with treatment resistant depression often have co-morbid anxiety, personality difficulties and drug or alcohol misuse and have been characterised as difficult, heartsink or problem personalities by general practitioners. Yet critical studies of interaction in medical settings suggest that the context may have a role in constructing the patient. A total of 12 audio-recorded routine consultations were analysed following guidelines for qualitative analysis of medical discourse. The interpretation focused on ways in which the context and structure of primary care consultations in a UK setting construct difficult encounters, which may lead to patients with treatment resistant depression being seen as difficult to manage in various ways. Three overarching observations were that presentation of multiple problems in multiple domains clash with the consultation format; that patients’ atypically high level of activity in a time-limited setting prevents patient-centred work; that the question and answer format restricts multifaceted discussions of social and emotional problems, preventing shared understandings emerging. However, although interactions appear uneasy, they are repaired and may be moderately palliative. Suggestions are made for re-orienting general practitioner work with treatment resistant depression towards long-term goal setting outside of the traditional consultation structure in order to develop shared understandings. [ABSTRACT FROM PUBLISHER]

Objectives: This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions. Methods: The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups. Results: In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organizational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals' behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation. Conclusions: Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multiprofessional activity. [ABSTRACT FROM AUTHOR]

Abstract: Primary care practitioners have an important role to play in the management of patients with psychosis; patients want easy access and see general practitioners (GPs) as having a role in both physical and mental health care. Better physical and mental health care is achieved through improved both proactive and reactive care. These components are enhanced by high-quality practice systems and liaison with specialist services. GPs need to be alert to potential psychosis in order to facilitate early treatment during first episodes; they may be the first contact during a relapse or crisis, and well-coordinated care with specialist teams is essential at this time. Patients under specialist teams may need support from care coordinators and others to develop the trust in primary care that can facilitate improved physical care and provide an alternative point of care in times of crisis. For patients no longer in contact with specialist services, GPs need to provide proactive care, screening for psychosocial needs, and reviewing medication and mental state. Specialist workers will increasingly provide support to primary care in order to improve the quality of this GP-led care. [Copyright &y& Elsevier]

The role of the primary care graduate mental health worker (GMHW) was developed to improve the availability of mental health services within primary care. However, little is known concerning the impact of the role upon primary care mental health. Semistructured interviews were undertaken with 27 key stakeholders (12 clients, 10 managers/supervisors, 5 general practitioners) who had experience of the GMHW role and activities provided. Thematic analysis of interview transcripts highlighted four main themes: Access to primary care mental health, Inappropriate referrals, GMHW characteristics, and Role developments. All participant groups highlighted a range of ways in which the GMHW role was making significant contributions to primary care mental health. Many of these were associated with increasing access to mental health services afforded by the range of interventions provided. Benefits, however, may exclude working clients who expressed concerns about a lack of flexibility in the appointment times offered. Concerns arise as a consequence of inappropriate referrals made by some general practitioners. Such referrals were, in part, motivated by a belief that developments in primary care mental health should have been directed towards clients with more severe difficulties. In conclusion, this study suggests that the GMHW role is having a significant impact upon primary care mental health. Attempts to improve primary care mental health through the incorporation of the GMHW role within stepped care models of mental health service delivery should be encouraged. [ABSTRACT FROM AUTHOR]

An editorial is presented on the development of primary care. Topics mentioned include the management of healthcare delivery, the technology-supported self-care such as contraception advice and blood pressure monitoring, and the public health management. Also mentioned are the role of general practitioners (GPs) in primary care, the monitoring of health services, and the importance of primary care to public health development.

The authors' reflect on the importance of the fit to work medical assessment regulation for the improvement of employees' health in Great Britain. Topics discussed include the mental health problems diagnosis, the patients management, and the regulation on general practitioners (GP). Also mentioned are the employees' health benefits and the decision making in health management.

Background: Problem statement: Care for individuals who are marginalised and have complex needs is poor due to both reduced access and poor continuity. Improved access to treatment requires to improvement to both. Previously access has usually been measured quantitatively while there has been a trend to seeing continuity as an 'experience' encompassing relationship, flexibility and organisation of care. Purpose: To develop a causal model for barriers and facilitators of access to and continuity of healthcare care for individuals with complex needs using data from offenders as an exemplary group. Methods: Design: Mixed-method, exploratory synthesis utilising a Realistic Evaluation framework to describe outcomes of interest (access and continuity)and then examine data streams to identify causal influences. Data: Three related data and analysis streams: quantitative analysis of data about care from structured interviews with 200 offenders ; qualitative (pre-coded and thematic) analysis of 25 offender interviews and three focus groups; and two whole-organisation case studies and six mini 'best-practice' case studies from England. Setting: Health and criminal justice systems covering two local authorities in the south west and south east of England and six additional case study sites. Participants: 200 offenders and 35 practitioners and managers. Results: Healthcare was reported as disrupted, with barriers to access and ongoing care; there was quantitative evidence of continuity for those with substance misuse but not for those with mental health problems. In the new model developed from the data, continuity was conceptualised as a continuation of access with the same practitioner, a different practitioner in the same team, or a different team. In contrast we described how organisational and practitioner factors contribute to both initial and ongoing continuity of access. Services needed well engineered access arrangements as well as to demonstrate they have treatments worth receiving to sceptical clients; initial distrust needed to be overcome with skilful practitioner interactions in order to promote continuity; and organisational integrating functions such as liaison, pathways, data sharing and colocation could all play a part in creating continuity but practitioners need to be empowered to be flexible. Conclusions: Access and continuity are best seen as a continuum. By considering organisational and interpersonal factors that contribute to ongoing access, those who provide and commission care for people with complex conditions and from marginalised communities can use the model to specify practitioner behaviours and service configurations which are likely to be helpful in different contexts. [ABSTRACT FROM AUTHOR]

Abstract: An understanding of patients’ perspectives is crucial to improving engagement with health care services. For older people who may not wish to bother medical professionals with problems of living such as depression, such exploration becomes critical. General practitioners (GPs), nurses and counsellors working in 18 South London primary care teams were interviewed about their perceptions of depression in older people. All three professional groups shared a predominantly psychosocial model of the causes of depression. While presentation of somatic symptoms was seen as common in all age groups, identification of depression in older patients was complicated by co-existent physical illnesses. GPs reported that older patients rarely mentioned psychological difficulties, but practice nurses felt that older people were less inhibited in talking to them about “non-medical” problems. Many older people were perceived to regard symptoms of depression as a normal consequence of ageing and not to think it appropriate to mention non-physical problems in a medical consultation. Men were thought to be particularly reluctant to disclose emotional distress and were more vulnerable to severe depression and suicide. Some GPs had mixed feelings about offering medication to address what they believed to be the consequences of loneliness and social isolation. Participants thought that many older people regard depression as a “sign of weakness” and the perceived stigma of mental illness was widely recognised as a barrier to seeking help. Cultural variations in illness beliefs, especially the attribution of symptoms, were thought to profoundly influence the help-seeking behaviour of elders from minority ethnic groups. Families were identified as the main source of both support and distress; and as such their influence could be crucial to the identification and treatment of depression in older people. [Copyright &y& Elsevier]