Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities.

BACKGROUND: The purpose of the study was to improve the quality of primary mental healthcare in underserved communities through involvement with the wider primary care team members and local community agencies. METHODS: We developed training intended for all GP practice staff which included elements of knowledge transfer, systems review and active linking. Seven GP Practices in four localities (North West England, UK) took part in the training. Qualitative evaluation was conducted using thirteen semi-structured interviews and two focus groups in six of the participating practices; analysis used principles of Framework Analysis. RESULTS: Staff who had engaged with the training programme reported increased awareness, recognition and respect for the needs of patients from under-served communities. We received reports of changes in style and content of interactions, particularly amongst receptionists, and evidence of system change. In addition, the training program increased awareness of - and encouraged signposting to - community agencies within the practice locality. CONCLUSIONS: This study demonstrates how engaging with practices and delivering training in a changing health care system might best be attempted. The importance of engaging with community agencies is clear, as is the use of the AMP model as a template for further research.

Slaying the dragon myth: an ethnographic study of receptionists in UK general practice.

BACKGROUND: General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful 'gatekeepers'. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience. AIM: To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work. DESIGN AND SETTING: Ethnographic observation in seven urban general practices in the north-west of England. METHOD: Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters. RESULTS: Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to 'play' the system. CONCLUSION: Framing the receptionist-patient encounter as one between the 'powerful' and the 'vulnerable' gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings.

Improving access to psychosocial interventions for common mental health problems in the United Kingdom: narrative review and development of a conceptual model for complex interventions.

BACKGROUND: In the United Kingdom and worldwide, there is significant policy interest in improving the quality of care for patients with mental health disorders and distress. Improving quality of care means addressing not only the effectiveness of interventions but also the issue of limited access to care. Research to date into improving access to mental health care has not been strongly rooted within a conceptual model, nor has it systematically identified the different elements of the patient journey from identification of illness to receipt of care. This paper set out to review core concepts underlying patient access to mental health care, synthesise these to develop a conceptual model of access, and consider the implications of the model for the development and evaluation of interventions for groups with poor access to mental health care such as older people and ethnic minorities. METHODS: Narrative review of the literature to identify concepts underlying patient access to mental health care, and synthesis into a conceptual model to support the delivery and evaluation of complex interventions to improve access to mental health care. RESULTS: The narrative review adopted a process model of access to care, incorporating interventions at three levels. The levels comprise (a) community engagement (b) addressing the quality of interactions in primary care and (c) the development and delivery of tailored psychosocial interventions. CONCLUSIONS: The model we propose can form the basis for the development and evaluation of complex interventions in access to mental health care. We highlight the key methodological challenges in evaluating the overall impact of access interventions, and assessing the relative contribution of the different elements of the model.

The space of access to primary mental health care: a qualitative case study.

Guided by theoretical perspectives of relational social science, this paper draws on reanalyses of multiple qualitative datasets related to a multi-ethnic, economically disadvantaged area in Liverpool, UK, with the aim to advance general understanding of access to primary mental health care while using local Somali minority as an instrumental focus. The findings generate a novel concept: the space of access. The shape and dynamics of the space of access are determined by at least four fields of tensions: understandings of area and community; cognitive mapping of mental well-being, illness and care; positioning of primary care services; and dynamics of resources beyond the 'medical zone' of care. The conclusions indicate a need for de-centring and re-connecting the role of medical professionals within primary care which itself needs to be transformed by endorsement of multiple avenues of access to diverse support and intrepid communication among all involved actors.

Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence.

BACKGROUND: Common mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care. METHODS: We began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users. CONCLUSIONS: Our methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

Doctors' understanding of palliative care.

Palliative care has been challenged to share its message with a wider audience, and for many years it has been articulating an approach that is suitable for all patients. However, it is not clear how widely this message has been accepted. As part of a study into end-of-life care for heart failure, we conducted seven focus groups with doctors in general practice, palliative medicine, cardiology, geriatrics and general medicine. In these, we explored doctors' understanding of palliative care. Participants displayed a reasonable grasp of the wider concept of palliative care, but the specialists' role was ill-defined, reflected in scepticism about their place outside of cancer. Perceptions of palliative care fell into three broad areas: it was more than a service, about managing dying, and the concern of nurses, rather than doctors. Palliative care was welcomed as providing permission to fail, whilst representing a dilemma between quantity and quality of life for the interviewees. Our work suggests that specialist palliative care has been partially successful in getting their message across, and poor understanding or receptivity are not major barriers to implementing palliative care. Educational or other interventions to implement change in palliative care need to acknowledge the complex interaction of factors influencing physicians' behaviour.

Health professionals' responses to the introduction of a home telehealth service.

An ethnographic (participant observation) study was undertaken of the socio-technical processes involved in the implementation, within a randomized controlled trial, of a home telehealth nursing service for patients with chronic obstructive pulmonary disease (COPD). Ethnographic field notes were taken about technology-related tasks and the interplay between the research team and the 12 nurses who were to use the telehealth equipment. Views of the technology were linked to views of professional self-image and status. The technology was sometimes seen as unhelpful in establishing effective relationships with patients. Considerable work by all participants, over a period of months, was required to develop the technology in ways that minimized the risk to the stability of the specialist service and existing nurse-patient relationships. Our work highlights the complex problems that health professionals encounter when they try to integrate new technologies into routine service delivery. The concerns arising from the interplay of new technology with existing professional practices and relationships go beyond simple issues of training.

Negotiating palliative care expertise in the medical world.

This paper explores the relationship between palliative medicine and the wider medical world. It draws on data from a focus group study in which doctors from a range of specialties talked about developing palliative care for patients with heart failure. In outlining views of the organisation of care, participants engaged in a process of negotiation about the roles and expertise of their own, and other, specialties. Our analysis considers the expertise of palliative medicine with reference to its technical and indeterminate components. It shows how these are used to promote and challenge boundaries between medical specialties and with nursing. The boundaries constructed on palliative medicine's technical contribution to care are regarded as particularly coherent within orthodox medicine. In contrast, its indeterminate expertise, represented by the 'holistic' and 'psychosocial' agendas, is potentially compromising in a medical world that prizes science and rationality. We show how the coherence of both kinds of expertise is contested by moves to extend palliative care beyond its traditional temporal (end-of-life) and pathological (cancer) fields of practice.

Doctors' perceptions of palliative care for heart failure: focus group study.

OBJECTIVES: To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change. DESIGN: Qualitative study with focus groups. SETTING: North west England. PARTICIPANTS: General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine. RESULTS: Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure. CONCLUSIONS: Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.