Patients' willingness to attend the NHS cardiovascular health checks in primary care: a qualitative interview study.

BACKGROUND: The NHS Cardiovascular Health Check (NHSHC) programme was introduced in England in 2009 to reduce cardiovascular disease mortality and morbidity for all patients aged 40 to 74 years old. Programme cost-effectiveness was based on an assumed uptake of 75% but current estimates of uptake in primary care are less than 50%. The purpose of this study was to identify factors influencing patients' willingness to attend an NHSHC. For those who attended, their views, experiences and their future willingness to engage in the programme were explored. METHOD: Telephone or face-to-face interviews were conducted with patients who had recently been invited for an NHSHC by a letter from four general practices in Torbay, England. Patients were purposefully sampled (by gender, age, attendance status). Interviews were audio recorded, transcribed verbatim and analysed thematically. RESULTS: 17 attendees and 10 non-attendees were interviewed. Patients who attended an NHSHC viewed it as worthwhile. Proactive attitudes towards their health, a desire to prevent disease before they developed symptoms, and a willingness to accept screening and health check invitations motivated many individuals to attend. Non-attendees cited not seeing the NHSHC as a priority, or how it differed from regular monitoring already received for other conditions as barriers to attendance. Some non-attendees actively avoided GP practices when feeling well, while others did not want to waste health professionals' time. Misunderstandings of what the NHSHC involved and negative views of what the likely outcome might be were common. CONCLUSION: While a minority of non-attendees simply had made an informed choice not to have an NHSHC, improving the clarity and brevity of invitational materials, better advertising, and simple administrative interventions such as sending reminder letters, have considerable potential to improve NHSHC uptake.

Trust, negotiation, and communication: young adults' experiences of primary care services.

BACKGROUND: Young adulthood is an important transitional period during which there is a higher risk of individuals engaging in behaviours which could have a lasting impact on their health. Research has shown that young adults are the lowest responders to surveys about healthcare experiences and are also the least satisfied with the care they receive. However, the factors contributing to this reduced satisfaction are not clear. The focus of our research was to explore the needs and experiences of young adults around healthcare services with an aim of finding out possible reasons for lower satisfaction. METHODS: Twenty young adults were interviewed at GP surgeries and at a local young adult advice agency, exploring their experiences and use of primary care services. Interviews were analysed using thematic analysis. RESULTS: The use of primary care services varied amongst the young adult interviewees. Many interviewees reported positive experiences; those who did not linked their negative experiences to difficulties in negotiating their care with the health care system, and reported issues with trust, and communication difficulties. Most of the interviewees were unaware of the use of patient surveys to inform healthcare planning and delivery and were not inclined to take part, mainly because of the length of surveys and lack of interest in the topic area. CONCLUSIONS: In order to effectively address the health needs of young adults, young adults need to be educated about their rights as patients, and how to most efficiently use primary care services. GPs should be alert to effective means of approaching and handling the healthcare needs of young adults. A flexible, varied approach is needed to gathering high quality data from this group in order to provide services with information on the changes necessary for making primary care services more accessible for young adults.

"The Monkey on Your Shoulder": A Qualitative Study of Lymphoedema Patients' Attitudes to and Experiences of Acupuncture and Moxibustion.

Background. Lymphoedema, a distressing consequence of cancer treatment, has significant negative impact on health-related quality of life. Multidisciplinary approaches are needed to improve physical and psychosocial wellbeing. Acupuncture and moxibustion (acu/moxa), two modalities of traditional East Asian medicine, may contribute to improved outcomes for cancer survivors with lymphoedema. Aim. To explore how patients with lymphoedema secondary to cancer treatment perceive and experience acu/moxa treatment. Design and Setting. A qualitative focus group study, nested in a 3-step mixed methods observational study, was carried out in a cancer drop-in and information centre in north-west London. Methods. Six focus groups and one telephone interview were conducted with 23 survivors of breast or head and neck cancer, who had completed up to 13 acu/moxa treatments. Scripts were transcribed, coded, and analysed to identify salient and overarching themes. Results. Participants described feeling disempowered by cancer treatment and subsequent diagnosis of lymphoedema. Acu/moxa was valued for its whole-person approach and for time spent with a practitioner who cared, listened, and responded. Participants reported changes in physical and psychosocial health, including increased energy levels and reduced pain and discomfort, and feelings of empowerment, personal control, and acceptance. Many were motivated to improve self-care. Conclusion. Many participants who received acu/moxa treatment reported improved wellbeing and a more proactive attitude towards self-care.

The use of patient experience survey data by out-of-hours primary care services: a qualitative interview study.

BACKGROUND: English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done. OBJECTIVES: We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS). METHODS: A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews. RESULTS: Although most providers regularly audited their patients' experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form. CONCLUSIONS: The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.

Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial.

BACKGROUND: Evidence suggests acupuncture may be effective for treating the symptoms of knee osteoarthritis. Offering this in a group setting may offer cost savings. The aim of this study was to establish the feasibility of a definitive trial to assess the clinical and cost-effectiveness of Western medical acupuncture given in groups, or given individually, for adults with severe knee pain attributable to osteoarthritis. METHODS: A pilot randomised controlled trial (RCT) was conducted. Participants were recruited from seven general practices in Plymouth, Devon. Acupuncture was provided, at a dosage that increased up to and including electroacupuncture if no pain relief was reported, by one experienced acupuncturist in a community clinic. Potentially eligible adults aged at least 45 years with knee osteoarthritis were identified from practice registers, screened and randomised to either: (1) standardised advice and exercise booklet alone ('standard'); (2) booklet plus group acupuncture ('group'); and (3) booklet plus individual acupuncture ('individual'). Both acupuncture arms received up to ten treatments over 12 weeks. Recruitment, retention and data completion rates were recorded, and participants completed questionnaires on acceptability. We collected pain, stiffness and function data (using the Western Ontario McMaster Universities Osteoarthritis Index; WOMAC) and general health (EQ-5D) and economic measures at baseline and 14 weeks post-randomisation. RESULTS: We screened 149 people and randomised 60 (40 %), 20 per arm. The overall 14 week follow-up rate was 77 %, but only 70 % in the 'standard' group; 4.1 % of data points were missing. The study was acceptable to participants. Changes in WOMAC pain score (intention to treat complete case analysis) from baseline to 14 week follow-up were: 'standard', 0.4 (95 % confidence interval (CI) -1.4, 2.2, n = 14); 'group' -3.2 (95 % CI -5.1, -1.4, n = 17); 'individual' -2.4 (95 % CI -4.1, -0.7, n = 15). CONCLUSIONS: A definitive three-arm trial is feasible. Further follow-up reminders, minimum data collection and incentives should be considered to improve participant retention in the follow-up processes in the standardised advice and exercise booklet arm. TRIAL REGISTRATION: ISRCTN05305406.

Transferring information to an out-of-hours primary care service for patients with palliative care needs: an action research study to improve the use of handover forms.

AIM: To work with service users and providers to optimise the design and implementation of handover forms to support the transfer of information between daytime and out-of-hours primary care services for patients with palliative care needs. BACKGROUND: There is a need for improved informational continuity between daytime and out-of-hours primary care services for patients with palliative care needs. Research suggests that while handover forms are vital to ensure continuity of care, they remain underused for such patients. Audit work in an out-of-hours primary care service in South West England identified that their current system of handover forms was underused. METHODS: An action research study consisting of two phases was undertaken. In phase one, the views of general practitioners and nurses working in the out-of-hours and daytime primary care services (29 health professionals) in Devon (population c.1.4 million) and patients with palliative care needs and their carers (8 participants) were investigated using qualitative interviews and focus group methods. Participants' views on the content and use of handover forms, and of the systems supporting their generation were sought. In phase two, additional feedback from the health professional stakeholder groups was collected and collaborative work undertaken with the out-of-hours service to implement recommendations emerging from the qualitative research. Findings Respondents identified variable use of handover forms and inconsistent practice in terms of: who was responsible for generating and updating forms; when and where they were discussed in primary care; the criteria used to define which patient needed a form; and the information forms should contain. There was uncertainty about how handover forms were used by the out-of-hours service and concerns about incomplete access to forms for certain groups of staff. An action plan to improve the existing system was developed. This included distribution of educational materials (desktop guide, newsletter) to key stakeholders, and the modification of information systems to facilitate the updating of messages and the accessibility of electronic records for previously under-served staff.

Challenges to the credibility of patient feedback in primary healthcare settings: a qualitative study.

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.

'All in the same boat': a qualitative study of patients' attitudes and experiences in group acupuncture clinics.

BACKGROUND: Group acupuncture clinics have been introduced in a London hospital and in two general practices in Hertfordshire for the treatment of knee osteoarthritis (OA). Encouraging preliminary reports have been published of the efficacy of the treatment delivered in this setting but its acceptability to patients has not yet been established. The aim was to investigate the acceptability and perceived advantages and disadvantages of acupuncture delivered in the group setting for the treatment of knee OA. METHODS: Semistructured interviews were conducted with 16 patients in their own homes and with four nurses over the telephone. Interviews were recorded, transcribed, fully anonymised and analysed thematically. RESULTS: Group acupuncture was delivered with enthusiasm by nurses, was acceptable and popular with patients and recognised to be cost-efficient. Factors affecting acceptability were situational, interpersonal and intrapersonal. Situational factors included adequacy of the physical space used, flexibility of the appointment system and the changing and adaptable nature of the group. Interpersonal factors were mutual support, the exchange of information, the provision of mixed or single-sex sessions and the role of the acupuncture nurse. Intrapersonal factors that increased acceptability were less clear, but nurses expressed the view that the group setting was less suitable for patients with complex conditions or severe pain. CONCLUSIONS: Acceptability is very high and may be maximised by taking a number of factors into account: full information should be provided before treatment begins; flexibility should be maintained in the appointment system and different levels of contact between fellow patients should be fostered; sufficient space and staffing should be provided and single-sex groups used wherever possible.

Multisource feedback questionnaires in appraisal and for revalidation: a qualitative study in UK general practice.

BACKGROUND: UK revalidation plans for doctors include obtaining multisource feedback from patient and colleague questionnaires as part of the supporting information for appraisal and revalidation. AIM: To investigate GPs' and appraisers' views of using multisource feedback data in appraisal, and of the emerging links between multisource feedback, appraisal, and revalidation. DESIGN AND SETTING: A qualitative study in UK general practice. METHOD: In total, 12 GPs who had recently completed the General Medical Council multisource feedback questionnaires and 12 appraisers undertook a semi-structured, telephone interview. A thematic analysis was performed. RESULTS: Participants supported multisource feedback for formative development, although most expressed concerns about some elements of its methodology (for example, 'self' selection of colleagues, or whether patients and colleagues can provide objective feedback). Some participants reported difficulties in understanding benchmark data and some were upset by their scores. Most accepted the links between appraisal and revalidation, and that multisource feedback could make a positive contribution. However, tensions between the formative processes of appraisal and the summative function of revalidation were identified. CONCLUSION: Participants valued multisource feedback as part of formative assessment and saw a role for it in appraisal. However, concerns about some elements of multisource feedback methodology may undermine its credibility as a tool for identifying poor performance. Proposals linking multisource feedback, appraisal, and revalidation may limit the use of multisource feedback and appraisal for learning and development by some doctors. Careful consideration is required with respect to promoting the accuracy and credibility of such feedback processes so that their use for learning and development, and for revalidation, is maximised.