How QOF is shaping primary care review consultations: a longitudinal qualitative study

Chew‐Graham, Carolyn; Hunter, Cheryl; Langer, Susanne; Stenhoff, Alexandra; Drinkwater, Jessica; Guthrie, Elspeth; Salmon, Peter

doi:10.1186/1471-2296-14-103

Cited by 77 publications

(98 citation statements)

References 27 publications

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“…8,62,69,70 Recent changes to the English NHS have reformed many previous structures but continue to emphasise the importance of engagement and involvement. 22 At a local level, there are a wide variety of patient and user organisations.…”

Section: Patient and Public Involvement: Variety Of Organisationsmentioning

confidence: 99%

Commissioning for long-term conditions: hearing the voice of and engaging users – a qualitative multiple case study

Peckham

Wilson

Williams

et al. 2014

Health Services and Delivery Research

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BackgroundSome 15 million people in England have a long-term condition (LTC) but there is concern about whether or not the NHS meets their needs. To address this, consecutive governments have developed policies aimed at improving service delivery and patient and public engagement and involvement (PPEI). There has been little research that examines the impact or benefit of PPEI in commissioning. This project explored the role and impact of PPEI in commissioning for people with LTCs. The research was undertaken during a period of substantial change in the English NHS, which enabled us to observe how the NHS reforms in England impacted on approaches to PPEI.AimThe aim was to examine how commissioners enable voice and engagement of people with LTCs and identify what impact this has on the commissioning process and pattern of services. Our specific objectives were to (1) critically analyse the relationship between the public/patient voice and the impact on the commissioning process; (2) determine how changes in the commissioning process reshape local services; (3) explore whether or not any such changes in services impact on the patient experience; (4) identify if and how commissioners enable the voice and engagement of people with LTCs; and (5) identify how patient groups/patient representatives get their voice heard and what mechanisms and processes patients and the public use to make their voice heard.MethodsWe used a case study design examining the experience of PPEI in three LTC groups – diabetes, rheumatoid arthritis and neurological conditions – through three in-depth case studies. Our approach involved reviewing practice across the UK and then focusing on three geographical areas to examine practices of commissioning health care for people with LTCs, approaches to PPEI, patterns of services for people with LTCs and the activities of local patient and voluntary organisations for people with LTCs. The research had five phases and involved participatory and interactive methods of data collection and analysis.FindingsWe identified two key areas where improvements to practice in relation to PPEI can be made. The first relates to the framework or infrastructure arrangements for PPEI and how PPEI can be supported in the NHS and other organisations. To combat short-termism and the fragility of PPEI activities, sufficient resources need to be invested in developing shared understandings and sustaining relationships and infrastructures. The second area of action relates to the process for PPEI and how it should be undertaken.ConclusionAction needs to be taken by organisations at both national and local levels. PPEI is a circular process and, in itself, extremely fragile. This circular process can be ‘virtuous’– successful engagement leads to improved involvement and outcomes. However, where involvement is tokenistic or ends, patients and the public become disengaged and less involved and can be described as a ‘vicious circle’. In addition, we identified a number of key methodological issues and areas for further research that should be considered by research funders and researchers undertaking research in the area of PPEI, including a need for research on PPEI with young people.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Patient and Public Involvement: Variety Of Organisationsmentioning

confidence: 99%

Commissioning for long-term conditions: hearing the voice of and engaging users – a qualitative multiple case study

Peckham

Wilson

Williams

et al. 2014

Health Services and Delivery Research

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“…226 Opportunities during primary care reviews to identify depression and treat appropriately are frequently missed. 288 Once unscheduled care is accessed, reasons for its use are framed entirely within a physical context by patients and HCPs. 270 Patients' experience of unscheduled care reinforces future use.…”

Section: Reasons Why People With Long-term Conditions Use Unscheduledmentioning

confidence: 99%

“…185 Underlying contributing psychosocial factors are not addressed, which further increase the likelihood of more unscheduled care use. 288 …”

Section: Reasons Why People With Long-term Conditions Use Unscheduledmentioning

confidence: 99%

CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie

Afzal

Blakeley

et al. 2017

Programme Grants Appl Res

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BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…Patient needs, including problems with mood, outside the narrow protocol are made invisible by the process of review. 6 There appears to be a lack of congruence between patients' and professionals' conceptual language about depression. This, along with deficits in communication skills on the part of both patients and professionals, can lead to uncertainty about the nature of the problem and reduce opportunities to develop appropriate treatment strategies.…”

Section: Identifying Comorbid Depressionmentioning

confidence: 99%

Diabetes and depression in general practice: meeting the challenge of managing comorbidity

et al. 2014

View full text Add to dashboard Cite

How QOF is shaping primary care review consultations: a longitudinal qualitative study

Cited by 77 publications

References 27 publications

Commissioning for long-term conditions: hearing the voice of and engaging users – a qualitative multiple case study

Commissioning for long-term conditions: hearing the voice of and engaging users – a qualitative multiple case study

CHOICE: Choosing Health Options In Chronic Care Emergencies

Diabetes and depression in general practice: meeting the challenge of managing comorbidity

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