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Background: Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. Methods: Semi-structured interviews, with the data subjected to thematic analysis. Results: Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. Conclusions: The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care. [ABSTRACT FROM AUTHOR]

Background: Domestic violence and abuse (DVA) is common and damaging to health. UK national guidance advocates a multi-agency response to DVA, and domestic homicide reviews consistently recommend improved information-sharing between agencies. Identification of patients experiencing DVA in general practice may come from external information shared with the practice, such as police incident reports and multi-agency risk assessment conference (MARAC) reports. The aim of this study was to explore the views of general practitioners (GPs) and the police about sharing reports about DVA with GPs. Methods: Qualitative semi-structured interviews were conducted with GPs, police staff and a partnership manager. Participants were located across England and Wales. Thematic analysis was undertaken. Results: Interviews were conducted with 23 GPs, six police staff and one former partnership manager. Experiences of information-sharing with GPs about DVA varied. Participants described the relevance and value of external reports to GPs to help address the health consequences of DVA and safeguard patients. They balanced competing priorities when managing this information in the electronic medical record, namely visibility to GPs versus the risk of unintended disclosure to patients. GPs also spoke of the judgements they made about exploring DVA with patients based on external reports, which varied between abusive and non-abusive adults and children. Some felt constrained by short general practice consultations. Some police and GPs reflected on a loss of control when information about DVA was shared between agencies, and the risk of unintended consequences. Both police and GPs highlighted the importance of clear information and a shared understanding about responsibility for action. Conclusion: GPs regarded external reports about DVA as relevant to their role, but safely recording this information in the electronic medical record and using it to support patients required complex judgements. Both GPs and police staff emphasised the importance of clarity of information and responsibility for action when information was shared between agencies about patients affected by DVA. [ABSTRACT FROM AUTHOR]

Background: Distress is an expected emotional response to a negative life event. Experiences common in later life may trigger distress such as bereavement or loss of physical mobility. Distress is considered to be distinct to anxiety and/or depression and is not diagnostically labelled as a mental health problem. Older adults will often manage their own distress. Previous literature has focused on how younger adults self-manage mental health problems, however little research has explored the self-management strategies used by older people. There is a need to clarify the role of primary care in the context of distressed older adults who may consult healthcare services. This study seeks to address these gaps through qualitative methods. Methods: Keele University's ethical review panel approved this study. We recruited older adults who self-identified as distressed from community groups in North Staffordshire, England. Data were generated through semi-structured interviews and analysed thematically using constant comparison methods. A patient and public involvement and engagement group contributed to development of the research questions and methods, and offered their perspectives on the findings. Results: After 18 interviews data saturation was achieved. Key themes were: experiences of distress, actions taken, help-seeking from healthcare services and perceptions of treatments offered in primary care. Various forms of loss contributed to participants' distress. Participants initiated their own self-management strategies which included: pursuing independent activities, seeking social support and attending community groups and church. Five participants reported having consulted a GP when distressed but described a lack of acceptable treatments offered. Conclusions: To support older adults who are distressed, healthcare professionals in primary care should consider exploring how patients currently manage their mood problems, provide a broad range of information about potential management options and consider sign-posting older adults to community resources. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners' (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices. Methods: Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically. Results: This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics. Conclusions: Insight into GPs' negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices. [ABSTRACT FROM AUTHOR]

Background: The benefit of a "diagnosis" of pre-diabetes in very elderly patients is debated. How clinicians manage pre-diabetic blood results in these patients is unknown. This study aims to understand how clinicians are "diagnosing" older patients with pre-diabetic blood parameters. Methods: Semi-structured interviews and focus groups with health care staff (24 total participants) were conducted in the north of England. Interviews and focus groups were recorded, transcribed and analysed thematically. A grounded theory approach was taken with the theory of candidacy being used as a sensitising concept through which questions were framed and results interpreted. Results: There is a complex system of competing pressures that influence a clinician in deciding whether, and in what way, to inform a very elderly patient that they have pre-diabetes. The majority of clinicians adjust their management of pre-diabetes to the age and perceived risk/benefit for the patient. Whilst some clinicians choose not to inform certain patients of their blood results, many clinicians maintain, what could be seen as a somewhat paradoxical approach of labeling all older patients with pre-diabetes but downplaying the significance to the patient. The policy, organisational context, workload and professional constraints under which clinicians work, play a significant role in shaping how they deal with pre-diabetic blood results in the very elderly. Conclusion: There has been recent acknowledgement of how policy and organisational context frames decision-making, but there is a lack of evidence on how this influences uncertainty and dilemmas in decision-making in practice. These findings add further weight for the argument that treatment burden should be included in clinical guidelines. [ABSTRACT FROM AUTHOR]

Background: Previous research has highlighted that many GPs lack the confidence and knowledge to diagnose and manage people with CFS/ME. Following the development of an online training module for GPs, and an information pack and DVD for patients, this study explored the extent to which these resources can be implemented in routine primary care. Methods: Semi structured qualitative interviews were completed with patients and GPs across North West England. All interviews were transcribed and analysed using open exploratory thematic coding. Following this thematic analysis, the authors conducted a further theory-driven analysis of the data guided by Normalisation Process Theory. Results: When used in line with advice from the research team, the information resource and training were perceived as beneficial to both patients and GPs in the diagnosis and management of CFS/ME. However, 47 % of patients in this study did not receive the information pack from their GP. When the information pack was used, it was often incomplete, sent in the post, and GPs did not work with patients to discuss the materials. Only13 out of 21 practices completed the training module due to time pressures and the low priority placed on low prevalence, contentious, hard to manage conditions. When the module was completed, many GPs stated that it was not feasible to retain the key messages as they saw so few patients with the condition. Due to the complexity of the condition, GPs also believed that the diagnosis and management of CFS/ME should take place in a specialist care setting. Conclusion: While barriers to the implementation of training and resources for CFS/ME remain, there is a need to support CFS/ME patients to access reliable, evidence based information outside primary care. Our findings suggest that future research should develop an online resource for patients to support self-management. [ABSTRACT FROM AUTHOR]

Background: The rising volume of referrals to secondary care is a continuing concern in the NHS in England, with considerable resource implications. Referral management centres (RMCs) are one of a range of initiatives brought in to curtail this rise, but there is currently limited evidence for their effectiveness, and little is known about their mechanisms of action. This study aimed to gain a better understanding of how RMCs operate and the factors contributing to the achievement of their goals. Drawing on the principles of realist evaluation, we sought to elicit programme theories (the ideas and assumptions about how a programme works) and to identify the key issues to be considered when establishing or evaluating such schemes. Methods: Qualitative study with a purposive sample of health professionals and managers involved in the commissioning, set-up and running of four referral management centres in England and with GPs referring through these centres. Semi-structured interviews were conducted with 18 participants. Interviews were audio-recorded and transcribed. Data were analysed thematically. Results: Interview data highlighted the diverse aims and functions of RMCs, reflecting a range of underlying programme theories. These included the overarching theory that RMCs work by ensuring the best use of limited resources and three sub-theories, relating to how this could be achieved, namely, improving the quality of referrals and patient care, reducing referrals, and increasing efficiency in the referral process. The aims of the schemes, however, varied between sites and between stakeholders, and evolved significantly over time. Three themes were identified relating to the context in which RMCs were implemented and managed: the impact of practical and administrative difficulties; the importance and challenge of stakeholder buy-in; and the dependence of perceived effectiveness on the aims and priorities of the scheme. Many RMCs were described as successful by those involved, despite limited evidence of reduced referrals or cost-savings. Conclusions: The findings of this study have a number of implications for the development of similar schemes, with respect to the need to ensure clarity of aims and to identify indicators of success from the outset, to anticipate scheme evolution and plan for potential changes with respect to IT systems and referral processes. Also identified, is the need for further research that evaluates the effectiveness and cost effectiveness of particular models of RMC. [ABSTRACT FROM AUTHOR]

Background: Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice. Methods: We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention). Results: Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity. Conclusions: A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices. [ABSTRACT FROM AUTHOR]

Background: Traditional randomised controlled trials evaluating the effect of educational interventions in general practice may produce biased results as participants know they are being evaluated. We aimed to explore the acceptability of a McNulty-Zelen Cluster Randomised Control Trial (CRT) design which conceals from educational participants that they are in a RCT. Consent is obtained from a trusted third party considered appropriate to give consent on participants' behalf, intervention practice staff then choose whether to attend the offered education as would occur with normal continuing professional development. Methods: We undertook semi structured telephone interviews in England with 16 general practice (GP) staff involved in a RCT evaluating an educational intervention aimed at increasing chlamydia screening tests in general practice using the McNulty-Zelen design, 4 Primary Care (PC) Research Network officers, 5 Primary Care Trust leads in Public or sexual health, and one Research Ethics committee Chair. Interviews were undertaken by members of the original intervention evaluation McNulty-Zelen design RCT study team. These experienced qualitative interviewers used an agreed semi-structured interview schedule and were careful not to lead the participants. To further mitigate against bias, the data analysis was undertaken by a researcher (CR) not involved in the original RCT. Results: We reached data saturation and found five main themes; Support for the design: All found the McNulty-Zelen design acceptable because they considered that it generated more reliable evidence of the value of new educational interventions in real life GP settings. Lack of familiarity with study design: The design was novel to all. GP staff likened the evaluation using the McNulty-Zelen design to audit of their activities with feedback, which were to them a daily experience and therefore acceptable. Ethical considerations: Research stakeholders considered the consent procedure should be very clear and that these trial designs should go through at least a proportionate ethical review. GP staff were happy for the PCT leads to give consent on their behalf. GP research capacity and trial participation: GP staff considered the design increased generalisability, as staff who would not normally volunteer to participate in research due to perceived time constraints and paperwork might do so. Design 'worth it': All interviewees agreed that the advantages of the "more accurate" or "truer" results and information gained about uptake of workshops within Primary Care Trusts (PCTs) outweighed any disadvantages of the consent procedure. Discussion: Our RCT was evaluating the effect of an educational intervention to increase chlamydia screening tests in general practices where there was routine monitoring of testing rates; our participants may have been less enthusiastic about the design if it had been evaluating a more controversial educational area, or if data monitoring was not routine. Implications: The McNulty-Zelen design should be considered for the evaluation of educational interventions, but these designs should have clear consent protocols and proportionate ethical review. Trial registration: The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN9722. [ABSTRACT FROM AUTHOR]

Background: Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals. Methods: Nested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews. Results: Based on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients' health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems. Conclusion: The COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC. [ABSTRACT FROM AUTHOR]

Background: BATHE is a brief psychosocial intervention designed for physician use in patient consultations. The technique has gained some international recognition, but there is currently limited research evidence to demonstrate its acceptability and benefits to patient care. We conducted a pilot cluster randomised controlled trial and feasibility study to explore the use of BATHE as a key component of a person-focused intervention to improve the care of frequent attending patients in UK primary care. Methods: A nested qualitative interview study conducted within a pilot trial. The trial took place in six general practices in the South West of England. Eligible patients had been identified as being in the top 3% of attenders in the previous 12 months. General practitioners (GPs) were trained to use BATHE during a one-hour initial training session, and two top-up trainings which included feedback on implementation fidelity. GPs were asked to use BATHE with their study patients for a period of 12 months. 34 GPs were trained and documented using BATHE in a total of 577 consultations with eligible patients during the intervention period. At the end of the intervention period, GPs and study patients from the intervention practices were invited to take part in an interview. Interviews were semi-structured, audio-recorded and transcribed. Thematic analysis was used. Results: Eleven GPs and 16 patients took part in post-intervention interviews. Benefits of using BATHE included making consultations more person-centred, challenging assumptions that the GP knew what was going on for the patient and their main concerns, and supporting self-management. Difficulties reported included changing existing consultation habits, identifying appropriate consultations in which to use BATHE, and organisational constraints. Conclusions: The study suggests that using BATHE is both acceptable and beneficial but also highlighted some of the difficulties GPs had incorporating BATHE into routine practice. Strategies to reduce these difficulties are needed before the extent of the potential benefits of BATHE can be fully assessed. Trial registration: ISRCTN62939408 Prospectively registered on 24/06/2015. [ABSTRACT FROM AUTHOR]

Background: Anxiety and depression are common in older adults, but often under-recognised by GPs. Rather than perceiving themselves as suffering from anxiety or depression, older adults are more likely to self-identify as experiencing low mood, stress or distress. Older people may also feel responsible for managing their own mood problems. The Internet has the potential to support the self-management of distress through accessing health information or social support. Methods: This study was approved by Keele University's ethical review panel. Older adults who self-identified as experiencing distress were recruited from community groups in the West Midlands, England. To generate data, 'think-aloud' methods (including storyboards and an extract from an online forum) were embedded within semi-structured interviews. Thematic analysis, incorporating constant comparison methods, were used for data analysis. Results: Data saturation was achieved after 18 interviews. All participants reported having access to the Internet, but only a few described using the Internet to obtain general information or to conduct online purchases. Most participants described barriers to Internet use which included: a lack of interest, knowledge and confidence, a fear of technology and no trust in social media sites. Facilitators of Internet use included family encouragement and attending community groups which taught computer use. Female participants reported valuing the social contact provided by attending such groups. The Internet was seen as a source of health information once a GP had diagnosed a physical problem, but was not considered a source of information about distress or mood problems. Participants did not use the Internet to access social support and described a preference for face-to-face communication. Conclusions: GPs need to understand how an individual patient utilises the Internet. GPs should explore the self-management strategies already employed by older adults experiencing distress and understand that directing these older people to online support might not be acceptable. Encouraging distressed older adults to attend computer group classes might be useful as this permits face-to-face social contact, and may help to facilitate Internet use in the future. [ABSTRACT FROM AUTHOR]