Self-care in primary care: findings from a longitudinal comparison study

Abstract

Aim: To examine the effects of self-care training workshops for primary healthcare workers on frequently attending patients. Background: Interventions to promote selfcare in frequent users of primary care services have had mixed results. This paper reports an evaluation of a self-care initiative that aimed to develop a practice-based strategy to support self-care. Methods: A 12-month longitudinal-matched comparison study was carried out in seven intervention and four comparison practices. The intervention was a multidisciplinary training package delivered to Primary Care Trusts (PCTs) and practice staff in three workshops, over a three-to six-month period. Twenty-one managers, health professionals and other staff from participating practices and PCTs and 1454 patients were involved in the study. 'Frequently attending' patients were defined as having visited the practice more than eight times in the previous year, and were identified from practice registers and recruited by letter.Three sets of data were obtained: psychometric scores and other data from structured questionnaires; routinely collected data on use of healthcare services; and self-care beliefs and behaviour from qualitative interviews. Findings: Study recruitment rate was 20% and retention rate 75%. Of those recruited 66% were female and the majority (94.8%) were White. There was poor uptake of the training programme within the participating practices, with few changes agreed or implemented. Few healthcare professionals consented to take part in the evaluation. No significant changes were seen in patients' use of health services, psychometric scores or self-care beliefs or behaviour. Conclusion: The initiative did not show any effects during its pilot phase. Uptake and implementation were adversely affected by competing pressures for time and resources in primary care, coupled with a lack of engagement from primary health care professionals. IntroductionA substantial proportion of a General Practice's workload can be attributed to a relatively small proportion of the practice population who attend frequently. Definitions of 'frequent' attendance vary from threshold numbers of visits to a fixed proportion of patients with the highest consultation rate (Vedsted and Christensen, 2005). One systematic review reported that most studies used a definition of 9-14 visits per year (Gill and Sharpe, 1999), while a later review found the top 10% of attenders accounted for 30-50% of all contacts (Vedsted and Christensen, 2005). In the United Kingdom, analysis of appointment data from nine Sheffield Practices for 1997-1998 found that frequent attenders (attending more than 19 times per year) comprised 1.3% of the patient population, but generated 8.3% of consultations (Eve et al., 2000). Other UK studies, one in an isolated rural practice and one in a large teaching practice, found that frequent attenders (attending more than 11 times per year) created five times the consultation workload of a similar group (Heywood et al., 1998;Stewart and O'Dowd, 2002). The la...

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

“…In these tasks, HCPs, similar to patients, had to adopt a range of ‘technical’ and non-technical devices and processes into clinical practice. Factors influencing HCPs’ adoption included evidence that the solution works [ 14 , 60 ], the solution’s alignment with goals of the organisation within which the HCP worked [ 37 , 42 , 68 , 75 ], the integration of the solution into existing systems and practices [ 31 , 32 , 44 , 60 , 68 ], adaptability of the solution to learning and incorporating change [ 14 , 33 , 42 , 51 , 60 , 68 ], transfer of decision-making power to patients and the effect of the solution on patient-doctor relationship [ 37 , 49 , 68 , 71 ], time and resource constraints [ 54 , 78 ], incentives and motivation to use the solution [ 14 , 71 ], how the solution is promoted to the organisation within which the HCP worked [ 14 , 51 , 71 , 75 ], HCPs’ appraisal of level of patient skill and interest in the solution [ 42 , 71 , 80 ] and adaptability of the solution to current roles and responsibilities [ 14 , 32 , 44 , 49 , 60 , 68 ].…”

“…Along with Murray et al who described ‘implementers’ as a previously under-studied group [ 15 ], we also found that there is still very little literature on managers’ experiences. Factors affecting implementation included ability to deliver intended benefits of the solution, engaging effectively with business models, sustainable funding and resources, creating effective policies such as making adoption mandatory for HCPs, compatible commissions process across sectors and buy in senior leadership or active champions [ 14 , 33 , 47 , 54 , 78 ].…”

“…Support is another factor widely identified as a facilitator in SM [ 58 , 93 ]. In terms of organisations, HCPs expected interactive support from those implementing the solutions, such as training, manuals and workshops [ 42 , 49 , 54 , 76 , 78 ], but only attached constructive values, and were willing to adopt the solutions, if these types of support did not distract them from their duties. For example, in their study, which evaluated a self-care initiative at a practice level, Bagnall and colleagues found that one of the reasons why practices found it hard to assimilate necessary culture change needed to successfully implement the solution was the mismatched expectation of support and training by practice staff and noted that there were: Problems in running the training packages as envisaged due to the level of commitment required from practice staff and mismatched expectations of the course content: Facilitators expressed difficulties gaining access to practices and arranging sessions.…”

“…The feedback from the practices was that they expected to be told ‘how to’ implement self-care, whereas what they received were discussions on the nature of self-care. The package did in fact contain a number of ‘how to’ tools but interviewees did not mention these [ 54 ].…”