Kristian Pollock

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.

After you: conversations between patients and healthcare professionals in planning for end of life care

BackgroundThis study explores with patients, carers and health care professionals if, when and how Advance Care Planning conversations about patients’ preferences for place of care (and death) were facilitated and documented.MethodsThe study adopted an exploratory case study design using qualitative interviews, across five services delivering palliative care to cancer and non-cancer patients within an urban and rural English region. The study recruited 18 cases made up of patients (N = 18; 10 men; 8 women; median age 75); nominated relatives (N = 11; 7 women; 4 men; median age 65) and healthcare professionals (N = 15) caring for the patient. Data collection included: 18 initial interviews (nine separate interviews with patients and 9 joint interviews with patients and relatives) and follow up interviews in 6 cases (involving a total of 5 patients and 5 relatives) within one year of the first interview. Five group interviews were conducted with 15 healthcare professionals; 8 of whom also participated in follow up interviews to review their involvement with patients in our study.ResultsPatients demonstrated varying degrees of reticence, evasion or reluctance to initiate any conversations about end of life care preferences. Most assumed that staff would initiate such conversations, while staff were often hesitant to do so. Staff-identified barriers included the perceived risks of taking away hope and issues of timing. Staff were often guided by cues from the patient or by intuition about when to initiate these discussions.ConclusionsThis study provides insights into the complexities surrounding the initiation of Advance Care Planning involving conversations about end of life care preferences with patients who are identified as having palliative care needs, in particular in relation to the risks inherent in the process of having conversations where mortality must be acknowledged. Future research is needed to examine how to develop interventions to help initiate conversations to develop person centred plans to manage the end of life.

The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies

Objective To understand the contribution of the Medicines Use Review consultation to counseling practice in community pharmacies. Methods Qualitative study involving ten weeks of observations in two community pharmacies and interviews with patients and pharmacy staff. Results ‘Traditional’ counseling on prescription medicines involved the unilateral transfer of information from pharmacist to patient. Over-the-counter discussions were initiated by patients and offered more scope for patient participation. The recently introduced MUR service offers new opportunities for pharmacists’ role development in counseling patients about their medicines use. However, the study findings revealed that MUR consultations were brief encounters dominated by closed questions, enabling quick and easy completion of the MUR form. Interactions resembled counseling when handing out prescription medicines. Patients rarely asked questions and indeterminate issues were often circumvented by the pharmacist when they did. MURs did little to increase patients’ knowledge and rarely affected medicine use, although some felt reassured about their medicines. Pragmatic constraints of workload and pharmacy organisation undermined pharmacists’ capacity to implement the MUR service effectively. Conclusion Pharmacists failed to fully realise the opportunity offered by MURs being constrained by situational pressures. Practice implications Pharmacist consultation skills need to be reviewed if MURs are to realise their intended aims.

The practice assessment of student nurses by people who use mental health services

This paper reports on a participatory action research project focusing upon service-user involvement in the assessment of student mental health nurses in practice. The principle of student nurses being assessed by service-users was found to be desirable in theory. However, its implementation proved to be fraught with difficulty especially with regard to the concerns about increased workload and feelings of vulnerability amongst students. It is recommended that the model of assessment should be adjusted to that of review and that a program of service-users reviewing student nurses on placement be implemented and evaluated.

Is home always the best and preferred place of death

The current orthodoxy is that home is the best and preferred place of death for most people. Kristian Pollock questions these assumptions and calls for greater attention to improving the experience of dying in hospital and elsewhere

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.

Procedure versus process: ethical paradigms and the conduct of qualitative research

BackgroundResearch is fundamental to improving the quality of health care. The need for regulation of research is clear. However, the bureaucratic complexity of research governance has raised concerns that the regulatory mechanisms intended to protect participants now threaten to undermine or stifle the research enterprise, especially as this relates to sensitive topics and hard to reach groups.DiscussionMuch criticism of research governance has focused on long delays in obtaining ethical approvals, restrictions imposed on study conduct, and the inappropriateness of evaluating qualitative studies within the methodological and risk assessment frameworks applied to biomedical and clinical research. Less attention has been given to the different epistemologies underlying biomedical and qualitative investigation. The bioethical framework underpinning current regulatory structures is fundamentally at odds with the practice of emergent, negotiated micro-ethics required in qualitative research. The complex and shifting nature of real world settings delivers unanticipated ethical issues and (occasionally) genuine dilemmas which go beyond easy or formulaic ‘procedural’ resolution. This is not to say that qualitative studies are ‘unethical’ but that their ethical nature can only be safeguarded through the practice of ‘micro-ethics’ based on the judgement and integrity of researchers in the field.SummaryThis paper considers the implications of contrasting ethical paradigms for the conduct of qualitative research and the value of ‘empirical ethics’ as a means of liberating qualitative (and other) research from an outmoded and unduly restrictive research governance framework based on abstract prinicipalism, divorced from real world contexts and values.

Service user experiences of information delivery after a diagnosis of cancer: a qualitative study

Goals of workThis paper presents findings from a qualitative study investigating service users’ experiences of a patient information pathway after a diagnosis of cancer.Materials and methodsPatients (27) and relatives (20) were recruited from two identified Cancer Network sites representing a pathway that had been information mapped (Lung) and one which had not (Head and Neck). Respondents participated in up to three qualitative interviews in the year after diagnosis.Main resultsThe need for information in response to serious health problems has become widely accepted. Providing cancer patients and their carers with high-quality information throughout their care pathway is a policy priority. However, the study findings contribute to a growing body of evidence that far from embracing the active role of “expert patient”, many patients continue to prefer verbal to written information, to trust in health professionals as their primary and preferred source of information, and to be quite cautious and selective about what they want to know about their illness.ConclusionsGood information is regarded as a prerequisite for informed decision making and a primary means of coping with the stress of illness. However, patient attitudes to information are complex and encompass resistance, ambivalence and indifference, active engagement and interest. The study findings reinforce the need for health professionals to develop competence as skilled communicators, and for efficient local systems of information transfer between service agencies and health professionals as prerequisites for delivery of the timely, tailored and personalized information which patients require.

Public attitudes to death and dying in the UK: a review of published literature

Background Public attitudes are important in shaping public policy and the political will that determines future service provision. They also help to identify priorities for public education. This paper presents a review and synthesis of published literature on public attitudes to death and dying in the UK from 1990. Method The approach to the review was systematic and involved searching for published research in five databases combined with reviewing references proposed by experts in the field and following up relevant citations from identified sources. The selected sources were assessed by the review team and analysed using a thematic approach. Results The review identified 22 sources reporting 19 studies which met our criteria for inclusion in the descriptive analysis. Three descriptive themes were identified: preferences relating to death and dying, attitudes to euthanasia and attitudes to life-sustaining treatments and interventions. Conclusion The review outcomes challenge widespread assumptions about public attitudes to death and dying and identify the need for more rigorous work to better understand public views on dying and death. Such work is needed if public health services are to meet the expectations and reflect the wishes of individuals in this area in future.