Jonathan Q. Tritter

Patients' and health professionals' views on primary care for people with serious mental illness: focus group study

Abstract Objective To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting Six primary care trusts in the West Midlands. Participants Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and preferred to consult their own GP, who listened and was willing to learn, rather than be referred to a different GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms (“acted up”) to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness.

Focus group method and methodology: current practice and recent debate

This paper considers the contemporary use of focus groups as a method of data collection within qualitative research settings. The authors draw upon their own experiences of using focus groups in educational and ‘community’ user‐group environments in order to provide an overview of recent issues and debates surrounding the deployment of focus group methods and to pick out specific areas of contention in relation to both their epistemological and practical implications. Accordingly, the paper reflects on some of the realities of ‘doing’ focus groups whilst, at the same time, highlighting common problems and dilemmas which beginning researchers might encounter in their application. In turn, the paper raises a number of related issues around which there appears to have been a lack of academic discussion to date.

Revolution or evolution: the challenges of conceptualizing patient and public involvement in a consumerist world

Background  Changing the relationship between citizens and the state is at the heart of current policy reforms. Across England and the developed world, from Oslo to Ontario, Newcastle to Newquay, giving the public a more direct say in shaping the organization and delivery of healthcare services is central to the current health reform agenda. Realigning public services around those they serve, based on evidence from service user’s experiences, and designed with and by the people rather than simply on their behalf, is challenging the dominance of managerialism, marketization and bureaucratic expertise. Despite this attention there is limited conceptual and theoretical work to underpin policy and practice.

Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error

There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment’s response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick‐and‐carrot reforms of medical practice.

Pathways, Pyramids and Icebergs? Mapping the Links Between Dissatisfaction and Complaints

In this article the authors report the findings of a study of satisfaction, dissatisfaction and complaining, funded by the National Health Service Executive (NHSE). Although interest in these issues has increased with the introduction of the Citizens Charter Initiative and the continued growth of consumerism, few scholars have looked at the relationships between them. Satisfaction and dissatisfaction are commonly viewed as different facets of the same phenomenon. In turn, dissatisfaction is often understood to be a precursor to a complaint, or an embryonic one. The findings presented here suggest that satisfaction and dissatisfaction are linked but are essentially discrete constructs. The authors plot a variety of reactions to dissatisfaction and show that although excessive use is made of formal professional networks, few instances of dissatisfaction emerge as formal complaints. The article concludes that insufficient attention has been paid to understanding the everyday ways in which people cope with dissatisfaction and decisions not to voice a grievance.

Developing user involvement in a UK cancer network: professionals’ and users’ perspectives

This paper explores the results of a consensus development exercise that explored diverse perspectives and sought to identify key principles for the development of user involvement in a cancer network. The exercise took place within one of 34 UK cancer networks and was a collaboration between the NHS, two universities and two voluntary sector organizations. The paper explores professionals’ and users’ perspectives on user involvement with reference to the current sociopolitical context of user participation. British policy documents have placed increasing emphasis on issues of patient and public participation in the evaluation and development of health services, and the issue of lay participation represents an important aspect of a critical public health agenda. The project presented here shows that developing user involvement may be a complex task, with lack of consensus on key issues representing a significant barrier. Further, the data suggest that professional responses can partly be understood in relation to specific occupational standpoints and strategies that potentially allow professionals to define and limit users’ involvement. The implications of these findings and the impact of the consensus development process itself are discussed.

Public and patient participation in health care and health policy in the United Kingdom.

Since 1948, the United Kingdom (UK) has operated a National Health Service funded primarily through public taxation where health services are available based on need and free at the point of delivery with limited out-of-pocket copayment. Other European predominantly public taxation funded systems operate, for example, in Sweden, Denmark, Finland and Italy. Domestic policy decisions have been devolved from London and England to Wales, Scotland and Northern Ireland since 1999, although for the latter full devolution did not really occur until 2007. One consequence of devolution has been the growing divergence in policy and practice across the four countries within the United Kingdom. This digest summarizes the evolution of key policies across the United Kingdom and then identifies some of the distinctions between the four different administrations.

Disentangling patient and public involvement in healthcare decisions:why the difference matters

Patient and public involvement has become an integral aspect of many developed health systems and is judged to be an essential driver for reform. However, little attention has been paid to the distinctions between patients and the public, and the views of patients are often seen to encompass those of the general public. Using an ideal-type approach, we analyse crucial distinctions between patient involvement and public involvement using examples from Sweden and England. We highlight that patients have sectional interests as health service users in contrast to citizens who engage as a public policy agent reflecting societal interests. Patients draw on experiential knowledge and focus on output legitimacy and performance accountability, aim at typical representativeness, and a direct responsiveness to individual needs and preferences. In contrast, the public contributes with collective perspectives generated from diversity, centres on input legitimacy achieved through statistical representativeness, democratic accountability and indirect responsiveness to general citizen preferences. Thus, using patients as proxies for the public fails to achieve intended goals and benefits of involvement. We conclude that understanding and measuring the impact of patient and public involvement can only develop with the application of a clearer comprehension of the differences.

What are tests for? The implications of stuttering steps along the US patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physicians calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.

Exchanging knowledge on participation by EU health consumers and patients in research, quality and policy

Sponsored by ZonMw (The Netherlands Organisation for Health Research and Development) The Hague 11–12 April 2013