Janet Grime

Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study

Objective: To investigate patients’ perceptions of entitlement to time in general practice consultations for depression. Design: Qualitative study based on interviews with patients with mild to moderate depression. Setting: Eight general practices in the West Midlands and the regional membership of the Depression Alliance. Participants: 32 general practice patients and 30 respondents from the Depression Alliance. Results: An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients’ freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents’ accounts often showed a mismatch between their own sense of time entitlement and the doctors’ capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients’ illness and their decision to consult. Conclusions: Patients’ self imposed restraint in taking up doctors’ time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients’ anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients’ sense of entitlement to time. Far from acting as “consumers,” patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.

The role and value of written information for patients about individual medicines: a systematic review

Objective To review research on the role and value of written medicines information for patients from the perspective of patients and health professionals.

Strategies for reducing the prescribing of proton pump inhibitors (PPIs): patient self-regulation of treatment may be an under-exploited resource

Escalating costs of proton pump inhibitor (PPI) prescribing are a source of increasing concern. To reduce costs, GPs in the UK have been coming under pressure to restrict PPI prescribing in primary care, e.g. by raising the prescribing threshold for new patients, and encouraging established patients to accept a reduced dose, if not stop taking PPIs altogether. The need to reduce prescribing costs impacts on patients by redefining, i.e. reducing, the boundaries of clinical need for which PPI prescribing is deemed appropriate. This may be rationalised by the assumptions that much existing prescribing is inappropriate, is applied to relatively minor and trivial afflictions, and that patients put pressure on their doctors to initiate prescribing of PPIs, after which they are very reluctant to give them up. The research involved extended interviews to elicit GP and patient views and experience of PPI prescribing. A particular focus was a comparison of the views of patients and GPs, and the understanding and articulation of the patient perspective on PPIs, which has been largely absent from the discussion to date. The research identified six distinct strategies used by GPs in their efforts to reduce PPI prescribing. Contrary to what GPs often assumed to be the case, patients were generally quite receptive to changes to their medication, provided they had the security of knowing that their original prescription would be restored if necessary. Most doctors assessed their rationing strategies as having some impact, but acknowledged the difficulties in achieving a significant and sustained reduction in PPIs. In the study sample nearly half of the patients who had experienced a prescribing switch or step down had drifted back to their former brand, and, especially, higher dose. However, far from being overly and unreflectively dependent on PPIs, patients were often keen to reduce their medicine taking to a minimum. A number of respondents had taken the initiative in experimenting to find the lowest effective dose of PPIs required to control their symptoms. GPs varied in their attitudes to this form of treatment self-management, but less than half actively encouraged patients to regulate their treatment in this way. Our findings suggest that there is considerable scope for encouraging patients to self-regulate with PPIs, and that many patients would be willing to do this if the practice was sanctioned by their doctors. The anticipated benefits of increased self-regulation include an overall reduction in PPI prescribing and associated costs, and an increase in patient autonomy and control which is in line with the concordance model of the ideal relationship between patients and doctors.

Opportunity or threat? General practitioner perceptions of pharmacist prescribing

Objective In recent years prescribing rights have been extended beyond doctors and dentists in the UK, first to nurses and subsequently to pharmacists. The aim of the study was to explore general practitioner (GP) perceptions of the advantages and disadvantages of pharmacist supplementary prescribing and the future introduction of independent prescribing.

Troubling stoicism: Sociocultural influences and applications to health and illness behaviour

In light of the ambiguity of meanings attributed to the concept of stoicism we critically explore its use as a label to explain and describe health and illness behaviour, juxtaposing the often negative portrayals of contemporary stoicism against its classical and philosophical origins. By reflecting critically on the term ‘stoicism’, its application and dimensionality, we show how the term has evolved from classical to contemporary times in relation to changing context, and explore different understandings of the term across medical and health literature. We attend to sociocultural factors that are seen to influence the conceptualization of stoicism such as generational influences, gender and geographies. We make the assertion that by applying the label of ‘stoicism’ as it is known today, there is a danger of too readily accepting a term that masks particular health behaviours while missing an array of sociological factors that are important to how people deal with adversity arising from chronic health problems. We therefore encourage further questioning of this term.

Constructing osteoarthritis through discourse – a qualitative analysis of six patient information leaflets on osteoarthritis

BackgroundHealth service policy in the United Kingdom emphasises the importance of self-care by patients with chronic conditions. Written information for patients about their condition is seen as an important aid to help patients look after themselves. From a discourse analysis perspective written texts such as patient information leaflets do not simply describe the reality of a medical condition and its management but by drawing on some sorts of knowledge and evidence rather than others help construct the reality of that condition. This study explored patient information leaflets on osteoarthritis (OA) to see how OA was constructed and to consider the implications for self-care.MethodsSystematic and repeated readings of six patient information leaflets on osteoarthritis to look for similarities and differences across leaflets, contradictions within leaflets and the resources called on to make claims about the nature of OA and its management.ResultsBiomedical discourse of OA as a joint disease dominated. Only one leaflet included an illness discourse albeit limited, and was also the only one to feature patient experiences of living with OA. The leaflets had different views on the causes of OA including the role of lifestyle and ageing. Most emphasised patient responsibility for preventing the progression of OA. Advice about changing behaviour such as diet and exercise was not grounded in lived experience. There were inconsistent messages about using painkillers, exercise and the need to involve professionals when making changes to lifestyle.ConclusionThe nature of the discourse impacted on how OA and the respective roles of patients and professionals were depicted. Limited discourse on illness meant that the complexity of living with OA and its consequences was underestimated. Written information needs to shift from joint biology to helping patients live with osteoarthritis. Written information should incorporate patient experience and value it alongside biomedical knowledge.

Exploring the relationship between multi-morbidity, resilience and social connectedness across the lifecourse.

Multi-morbidity is receiving considerable attention in public policy, health and social care. From the perspective of the individual, multi-morbidity is a more complex experience than solely having a clinical diagnosis. In this article, we will argue that understanding multi-morbidity can be facilitated by considering the relationship between adversity (in this case multi-morbidity), resilience and social connectedness within a life course framework. This provides an approach that can capture the dynamics of social relationships, social connectedness and the fluctuations in the experience of multi-morbidity. We draw on a qualitative study of 17 people who have multiple conditions, but consider themselves as being able to maintain a sense of identity and self over time and in the face of adversity. From their accounts, a more varied picture emerges of living with multi-morbidity. This then depicts a more realistic representation of how each person shapes their multi-morbidity and resilient responses within their own social context, which can help to formulate more effective ways of supporting them.

Defining the Content of an Opportunistic Osteoarthritis Consultation With Primary Health Care Professionals: A Delphi Consensus Study

To define the core content for an opportunistic consultation between a health care professional (HCP) and a patient with osteoarthritis (OA) in primary care.

How do younger patients view long-term treatment with proton pump inhibitors?

Dyspepsia (also called indigestion or heartburn) is a common reason for consulting a general practitioner (GP). One of the medicines available for treating dyspepsia is a type of acid suppressant called a proton pump inhibitor or PPI. There is a growing concern over the rapid increase in prescribing PPI drugs and the escalating costs associated with this trend. There has been an effort to reduce prescribing of PPIs. Most patients who are prescribed these drugs are aged over 45 years. Younger patients (those under 45) are a minority but, in absolute terms, a sizeable number who could potentially be taking PPIs for many years and therefore be expensive. This is a group for whom the appropriateness of prescribing PPIs is often questioned because of the everyday and non-life threatening nature of gastric disorders. A widespread association between dyspeptic symptoms and features of adverse lifestyle that are, at least in principle, easily avoidable has led to the suggestion that PPIs might be used to support unhealthy lifestyles. The perspective of younger patients taking PPIs in the long term has been neglected. In this paper the accounts of ten younger respondents, from a large qualitative investigation of patient and GP perspectives on long-term PPI prescribing, are examined to gain insight into how younger patients viewed their stomach problem, the effectiveness of PPIs and long-term PPI taking. The findings showed a gap between patient experience and medical perception. The perspectives of younger patients need to be recognised in order to deal adequately with their concerns about illness and treat their gastrointestinal conditions effectively.

The great boundary crossing: Perceptions on training pharmacists as supplementary prescribers in the UK

Objective: To explore the perceptions of General Medical Practitioners and pharmacist supplementary prescribers of the training provided for qualification as a pharmacist supplementary prescriber, and the experience of pharmacist supplementary prescribers of subsequent continuing professional development in practice. Design: A qualitative study of pharmacists from the first wave of those trained to become pharmacist supplementary prescribers, comprising interviews, focus groups and documentary analysis of recorded critical incidents. Setting: The research was conducted in three general practices located in two primary care trusts in the UK Midlands. Each practice had a pharmacist supplementary prescriber. Eight pharmacist supplementary prescribers participated, seven of whom were prescribing, all in a general practice setting. Method: A practice-specific focus group was held in each of the three general practices. Two focus groups were held for pharmacists and seven pharmacists were interviewed, six of whom provided two or more critical incidents. Results: Pharmacists were critical of some aspects of the academic training but were unanimous in acknowledging the value of the period of learning in practice and the input of their Designated Medical Practitioner. Learning was recognized by both parties as being reciprocal. Pharmacists’ accounts illustrated a variety of ways in which they undertook continuing professional development, with learning on the job a key component. There was little consensus between General Practitioner partners in two of the practices on the appropriateness of pharmacist supplementary prescribing, discussion focusing on the acquisition of clinical skills. Some partners, particularly those who were Designated Medical Practitioners, saw potential benefits. Conclusion: The coaching relationship between General Practitioner Designated Medical Practitioners and pharmacists served to embed skills and enhance confidence.The reflection skills gained by the pharmacist supplementary prescribers during their academic learning period appear to be important in their subsequent work-based learning.