Background: In 2008, the English Department of Health appointed 16 'Integrated Care Pilots' which used a range of approaches to provide better integrated care. We report qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care.

BackgroundThe 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. AimTo investigate primary care providers' response to feedback on patient experience from a national survey. Design and settingQualitative interview study in 10 general practices from four primary care trusts in England. MethodSemi-structured interviews were conducted with GPs, practice nurses, and practice managers (n = 37). Transcripts were analysed thematically. ResultsAlthough 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. ConclusionAlthough, 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. Keywordsprimary healthcare; qualitative research; reliability and validity; surveys.

Objective To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

Background The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England. Methods We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes. Results No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term ‘care planning’. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term”reactive” care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described. Conclusions Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.

Despite the potential benefits of enhanced self-management, the review of the literature presented here suggests several possible problems associated with the presentation and implementation of initiatives such as the EPP programme. These include the possibility that advocates of public service improvements have on occasion been tempted to overstate the evidence for the relative and absolute effectiveness of lay-led self-management programmes. In addition, the varied experiences of those living with a chronic illness warn against promulgating rigid prescriptions about what patients -should think and do. The evidence to date is indicative of short-term benefits being derived from the provision of lay-led self-management programmes.

Recent UK policy has highlighted the importance of a young person's family in their care and the need for health professionals to work in partnership with young people and their parents. This research provides health professionals with an insight into how the responsibilities for different aspects of medicine management are shared between young people and their parents in the home. It highlights the dynamic nature of partnerships between parents and young people and the considerable role of young people in medicine management in the home, which contrasts with their more limited involvement in consultations with health care professionals. The findings are based on semi-structured interviews conducted in the participants' own homes, with 69 young people aged 8-15 years (43 young people with asthma; 26 young people with diabetes) and their parents (138 interviews in total), recruited through general practice (GP) surgeries.

In order to ensure optimal care, there is a need for the development of protocols tailored to the needs of young people with different conditions. These should preferably be devised in partnership between the young person, their parents and the school to ensure that the flexibility and support required for optimal management are offered.

Reaching a decision about whether and when to visit the doctor can be a difficult process for the patient. An early visit may cause the doctor to wonder why the patient chose to consult when the disease was self-limiting and symptoms would have settled without medical input. A late visit may cause the doctor to express dismay that the patient waited so long before consulting. In the UK primary care context of constrained resources and government calls for cautious healthcare spending, there is all the more pressure on both doctor and patient to meet only when necessary. A tendency on the part of health professionals to judge patients' decisions to consult as appropriate or not is already described. What is less well explored is the patient's experience of such judgment. Drawing on data from 52 video-elicitation interviews conducted in the English primary care setting, the present paper examines how patients seek to legitimise their decision to consult, and their struggles in doing so. The concern over wasting the doctor's time is expressed repeatedly through patients' narratives. Referring to the sociological literature, the history of ‘trivia’ in defining the role of general practice is discussed, and current public discourses seeking to assist the patient in developing appropriate consulting behaviour are considered and problematised. Whilst the patient is expected to have sufficient insight to inform timely consulting behaviour, it becomes clear that any attempt on the part of doctor or patient to define legitimate help-seeking is in fact elusive. Despite this, a significant moral dimension to what is deemed appropriate consulting by doctors and patients remains. The notion of candidacy is suggested as a suitable framework and way forward for encompassing these struggles to negotiate eligibility for medical time.