The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

BACKGROUND: This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. METHODS: We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. RESULTS: Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. CONCLUSIONS: While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study.

BACKGROUND: The successful introduction of new methods for managing medically unexplained symptoms in primary care is dependent to a large degree on the attitudes, experiences and expectations of practitioners. As part of an exploratory randomised controlled trial of reattribution training, we sought the views of participating practitioners on patients with medically unexplained symptoms, and on the value of and barriers to the implementation of reattribution in practice. METHODS: A nested attitudinal survey and qualitative study in sixteen primary care teams in north-west England. All practitioners participating in the trial (n = 74) were invited to complete a structured survey. Semi-structured interviews were undertaken with a purposive sub-sample of survey respondents, using a structured topic guide. Interview transcripts were used to identify key issues, concepts and themes, which were grouped to construct a conceptual framework: this framework was applied systematically to the data. RESULTS: Seventy (95%) of study participants responded to the survey. Survey respondents often found it stressful to work with patients with medically unexplained symptoms, though those who had received reattribution training were more optimistic about their ability to help them. Interview participants trained in reattribution (n = 12) reported that reattribution increased their confidence to practice in a difficult area, with heightened awareness, altered perceptions of these patients, improved opportunities for team-building and transferable skills. However general practitioners also reported potential barriers to the implementation of reattribution in routine clinical practice, at the level of the patient, the doctor, the consultation, diagnosis and the healthcare context. CONCLUSION: Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice.

Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms.

BACKGROUND: Reattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms. AIMS: To determine if practice-based training of GPs in reattribution changes doctor-patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration. METHOD: Cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual. RESULTS: With training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference -0.9, 95% CI -1.6 to -0.1; P=0.027) with no other effects on patient outcome or health contacts. CONCLUSIONS: Practice-based training in reattribution changed doctor-patient communication without improving outcome of patients with medically unexplained symptoms.

Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST).

BACKGROUND: The evidence for the effectiveness of reattribution training are limited, and optimal service delivery is not yet established. OBJECTIVES: The objectives of this study were to establish the feasibility and to optimize the service delivery and design of a definitive randomized controlled trial (RCT) of reattribution training for patients with medically unexplained symptoms (MUSs) in routine primary care. METHODOLOGY: The study was of a cluster RCT design with the practice as the unit of randomization. Health facilitator (HF)-delivered reattribution training was compared with no reattribution training. The primary outcome measure used is doctor-patient communication in the consultation. Quantitative and qualitative methods identify barriers to effectiveness. The acceptability and feasibility of the intervention were established by attendance rates and postal survey after completion of training. RESULTS: Sixteen practices and 70 family practitioners (FPs) were recruited with representative practice and FP characteristics. Six hours of HF reattribution training to FPs in the workplace proved feasible and acceptable with all 35 FPs completing the training. Feedback from 27 (77%) FPs who received training indicated that 25 (93%) FPs believed that specific and relevant learning achievements were made, 22 (82%) felt more confident and 21 (77%) thought the training was useful. CONCLUSION: HF-delivered reattribution training to whole practices is feasible and acceptable, and its effectiveness is measurable in routine primary care.