Cheryl Hunter
Trainee Clinical Psychologist at University of East London.
From April-September 2017, I was a researcher in health psychology, working with Professor Lucy Yardley on the development and evaluation of digital health interventions in a variety of areas.
From March 2015 - April 2017, I was a research fellow on the ASPIRE programme, conducting a process evaluation of an intervention in primary care which aims to promote adherence to best practice guidelines. See: http://medhealth.leeds.ac.uk/aspire.
From June 2013 until March 2015, I was a post-doc Research Officer working in the Health Services Research Unit at the Nuffield Department of Population Health, University of Oxford. This role involved developing and testing a generic patient-reported outcome measure for people with long-term conditions, one which can be used to monitor and improve clinical practice and patient self-management.
Between September 2010 and May 2013, I was a qualitative researcher working on a 5 year NIHR programme grant called CHOICE, investigating the use of unscheduled care services (e.g. A&E, out of hours GPs, walk-in centres) in people with long-term physical conditions.
I am interested in the lived experiences of people with long-term conditions and the experiences of family and carers, and in translating qualitative and quantitative research into practice and policy. I am interested in the intersection of physical and mental health, as well as service user involvement in research, service design and evaluation.
My PhD focused on the experiences of people who self-harmed and attended emergency departments, especially critically examining the practice of psychosocial assessment from the service user perspective.
From April-September 2017, I was a researcher in health psychology, working with Professor Lucy Yardley on the development and evaluation of digital health interventions in a variety of areas.
From March 2015 - April 2017, I was a research fellow on the ASPIRE programme, conducting a process evaluation of an intervention in primary care which aims to promote adherence to best practice guidelines. See: http://medhealth.leeds.ac.uk/aspire.
From June 2013 until March 2015, I was a post-doc Research Officer working in the Health Services Research Unit at the Nuffield Department of Population Health, University of Oxford. This role involved developing and testing a generic patient-reported outcome measure for people with long-term conditions, one which can be used to monitor and improve clinical practice and patient self-management.
Between September 2010 and May 2013, I was a qualitative researcher working on a 5 year NIHR programme grant called CHOICE, investigating the use of unscheduled care services (e.g. A&E, out of hours GPs, walk-in centres) in people with long-term physical conditions.
I am interested in the lived experiences of people with long-term conditions and the experiences of family and carers, and in translating qualitative and quantitative research into practice and policy. I am interested in the intersection of physical and mental health, as well as service user involvement in research, service design and evaluation.
My PhD focused on the experiences of people who self-harmed and attended emergency departments, especially critically examining the practice of psychosocial assessment from the service user perspective.
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Papers by Cheryl Hunter
Objectives To explore the views of a range of stakeholders regarding whether patient-reported outcome measures (PROMs) can be developed to measure key attributes of long-term conditions (LTCs) care in England, and the potential value of a single generic measure.
Design Qualitative semistructured interview study, analysed using a framework approach.
Participants and setting Interviews with 31 stakeholders from primary care, secondary care, social care, policy and patient-focused voluntary organisations in England.
Results There was broad support for a single PROM that could be used to measure outcomes for patients with any LTCs in any health or social care setting. Interviewees identified three desired uses for a PROM: to improve the quality of individual care; to increase people's engagement in their own care; and to monitor the performance of services. Interviewees felt that a PROM for LTCs should incorporate a mixture of traditional and non-traditional domains, such as functioning, empowerment and social participation, and be codesigned with patients and professional end-users. Stakeholders emphasised the need for a PROM to be feasible for practical implementation at the individual clinical level as a first priority. A number of concerns and potential problems were identified in relation to the application and interpretation of an LTC PROM.
Conclusions This study has demonstrated support for a single self-report outcome measure that reflects the priorities of people with LTCs, if such a measure can be shown to be meaningful and useful at the individual level. People with LTCs and professional end-users in health and social care should be involved in the development and evaluation of such a measure.
for health services. Psychosocial co-morbidity is associated with poorer quality of life and greater use of health care
in these patients but is often un-diagnosed or inadequately treated in primary care, where most care for these
patients is provided. We developed a brief intervention, delivered by ‘liaison health workers’ (LHWs), to address
psychosocial needs in the context of an integrated approach to physical and mental health. We report a qualitative
study in which we characterize the intervention through the experience of the patients receiving it and examine
how it was incorporated into primary care.
Methods: Qualitative study using patient and practice staff informants. We audio-recorded interviews with 29
patients offered the intervention (three had declined it or withdrawn) and 13 practice staff (GPs, nurses and
administrators). Analysis used a constant comparative approach.
Results: Most patients were enthusiastic about the LHWs, describing the intervention as mobilizing their motivation
for self-management. By contrast with other practitioners, patients experienced the LHWs as addressing their needs
holistically, being guided by patient needs rather than professional agendas, forming individual relationships with
patients and investing in patients and their capacity to change. Practices accommodated and accepted the LHWs,
but positioned them as peripheral to and separate from the priority of physical care.
Conclusions: Despite being a short-term intervention, patients described it as having enduring motivational
benefits. The elements of the intervention that patients described map onto the key features of motivating
interventions described by Self-Determination Theory. We suggest that the LHWs motivated patients to self-management
by: (i) respecting patients’ competence to decide on needs and priorities; (ii) forming relationships with patients as
individuals; and (iii) fostering patients’ sense of autonomy. While truly integrated primary care for patients with
long-term conditions such as COPD remains elusive, existing practice staff might adopt elements of the LHWs’
approach to enhance motivational change in patients with long-term conditions such as COPD.
Keywords: Primary care, Long-term conditions, Qualitative research, Motivational change, Psychosocial intervention
Background
Health outcomes for long-term conditions (LTCs) can be improved by lifestyle, dietary and condition management-related behaviour change. Primary care is an important setting for behaviour change work. Practitioners have identified barriers to this work, but there is little evidence examining practices of behaviour change in primary care consultations and how patients and practitioners perceive these practices.
Objective
To examine how behaviour change is engaged with in primary care consultations for LTCs and investigate how behaviour change is perceived by patients and practitioners.
Design
Multiperspective, longitudinal qualitative research involving six primary health-care practices in England. Consultations between patients with LTCs and health-care practitioners were audio-recorded. Semi-structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re-interviewed 3 months later. Framework analysis was applied to all data.
Participants
Thirty-two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners.
Results
Behaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.
Conclusion
Behaviour change work is often deflected or deferred by practitioners in consultations, who nevertheless vocalize support for its importance in interviews. This discrepancy between practitioners’ accounts and behaviours needs to be addressed within primary health-care organizations.
The role of anxiety in the use of urgent care in people with long term conditions is not fully understood. A systematic review was conducted with meta-analysis to examine the relationship between anxiety and future use of urgent healthcare among individuals with one of four long term conditions: diabetes; coronary heart disease, chronic obstructive pulmonary disease and asthma.
Methods
Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library were conducted These searches were supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts within the field about relevant studies. Studies were eligible for inclusion if they: a) used a standardised measure of anxiety, b) used prospective cohort design, c) included adult patients diagnosed with coronary heart disease (CHD), asthma, diabetes or chronic obstructive pulmonary disease (COPD), d) assessed urgent healthcare use prospectively. Data regarding participants, methodology, and association between anxiety and urgent care use was extracted from studies eligible for inclusion. Odds ratios were calculated for each study and pooled using random effects models.
Results
8 independent studies were identified for inclusion in the meta-analysis, with a total of 28,823 individual patients. Pooled effects indicate that anxiety is not associated with an increase in the use of urgent care (OR = 1.078, p = 0.476), regardless of the type of service, or type of medical condition.
Conclusions
Anxiety is not associated with increased use of urgent care. This finding is in contrast to similar studies which have investigated the role of depression as a risk factor for use of urgent care.
Keywords: Anxiety, Urgent care, Long term conditions, Diabetes' asthma, Chronic obstructive pulmonary disease, Coronary heart disease
We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.
Methods
Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.
Results
Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.
Conclusion
Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of ‘candidacy’ for specific emergency care services, was recursively shaped by previous experiences.
Practice implications
Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients’ judgements of candidacy and their perceptions of accessible expertise in alternative services.
Keywords
Healthcare utilisation; Primary health care; Patient experiences; Qualitative research; Longterm conditions; Unscheduled care; Emergency healthcare; Chronic obstructive pulmonary disease; Asthma; Diabetes; Coronary heart disease; Theory; Candidacy; Recursivity; Patient decision-making"
Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.
Methods
A longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach.
Results
Practitioners view consultations as a means of 'surveillance' of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the 'review' were subsumed to meet the patient's needs, focused on cancer and bereavement.
Conclusions
Routine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients' expectations of future care and socialize patients into becoming passive subjects of 'surveillance'. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.
Aim: We explored Health Care Professionals’ (HCPs) understandings of why patients with LTCs use UC, and the HCPs’ understanding of their role in relation to reducing UC use.
Design and setting: Qualitative study interviewing different types of HCP providing primary care or UC services in Northwest England.
Method: Semi-structured interviews conducted with 29 HCPs (six GPs; five out-of-hours GPs; four emergency department Doctors; two Practice Nurses; three Specialist Nurses; two District Nurses; seven Active Case Managers). Data analysed using framework analysis.
Results: HCPs viewed UC use as a necessary component of care for patients with LTCs. Those whose roles involved working to targets to reduce UC use described a tension between this and delivering optimum patient care. Three approaches to reducing UC were described: optimising the system; negotiating the system; and optimising the patient.
Conclusion: Current policy to reduce UC use does not take account of the perceptions of the HCPs who are expected to implement them. Lipsky’s theory of street-level bureaucrats provides a framework to understand how HCPs respond to imposed policies. HCPs did not see UC use as a problem and there was limited commitment to the policy targets. Therefore policy should aim for whole system change rather than reliance on individual HCPs to make changes in their practice.
"
Method: Interpretative phenomenological analysis was applied to 13 interviews with service users following hospital attendance, and 7 follow-up interviews conducted three months later.
Results: Few participants had a clear understanding of assessment's purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialize, this reinforced hopelessness and promoted disengagement from services.
Limitations: The study sample was small and the participants heterogeneous in terms of self-harm history, method and intent, which may limit the transferability of the findings to other settings. Only self-report data on clinical diagnosis was collected.
Conclusions: This was the first study to utilize an in-depth qualitative approach to investigate service user experiences of assessment and follow-up. The findings suggest that re-conceptualizing psychosocial assessment as primarily an opportunity to engage service users therapeutically may consequently affect how health services are perceived. In order to maintain benefits established during the hospital experience, follow-up needs to be timely and integrated with assessment.
Few qualitative papers specifically address UC in patients in these disease groups. Therefore our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to health care use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011 we identified 43 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. Review conducted between Spring 2009 and April 2011, with a further search December 2011.
Most papers reported on asthma (n=14) or on multiple or unspecified conditions (n=12). The most common methods reported were interviews (n=33) and focus groups (n=14) and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the ‘problem’ of UC, and health care, use in general, decontextualised from the lives of the patients using it.
Patients’ use of UC emerged as understandable, rational responses to pressing clinical need in situations where patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.
Objective
We investigated the views of service users and staff regarding contact-based interventions (e.g., letters, telephone calls or crisis cards) following self-harm.
Method
Self-harm patients recently discharged from an emergency department were selected using purposive sampling (n=11). Clinical staff from relevant service areas and voluntary staff took part in a focus group and individual interviews (n=10). Interviews were transcribed and thematic analyses were conducted using methods of constant comparison to ensure that emergent themes remained grounded in the data.
Results
Most service users and staff participants identified the period of time directly after discharge as the time of greatest need. A contact-based intervention was viewed by service users as a gesture of caring, which counteracted feelings of loneliness. Delivery by mental health specialists was preferred, initially by phone, but letters were considered helpful later. The intervention should be both genuine in delivery and linked to current services. Potential barriers included means of accessing the service and threats to privacy.
Conclusion
The findings suggest that an appropriate design for an intervention might be the provision of an information leaflet, telephone calls (soon after discharge), then letters (offering continuity of contact). Aspects of value and concern expressed by service users should be helpful to clinicians and service providers.
This paper aims to contribute to debates around researcher reflexivity by addressing the interpersonal aspects of interviewing both men and women who have self-harmed or attempted suicide. It is argued that Gadamer’s “fusion of horizons” is a useful concept for the IPA researcher as it encapsulates the fluctuating nature of personal positioning within the research: as we come towards an understanding of the participant, our past and present fuse and change our capacity to understand. In addition, it is argued that this process of reflection during data collection is the start of the analytic process, as our in/ability to connect and moments of fusion and fission with each individual highlight areas of preconception which need to be accounted for during analysis.
Talks by Cheryl Hunter
A multi-perspective, longitudinal qualitative study involving six primary health-care practices in England was conducted. Consultations between patients with LTCs and health-care practitioners were audio-recorded. Semi-structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re-interviewed 3 months later. Framework analysis was applied to all data.
Thirty-two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners (5 GPs, and 5 practice nurses) took part. Behaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.
The implications of this discrepancy between practitioners’ accounts and behaviours for both primary care practice and the care of people with LTCs will be discussed.
Objectives To explore the views of a range of stakeholders regarding whether patient-reported outcome measures (PROMs) can be developed to measure key attributes of long-term conditions (LTCs) care in England, and the potential value of a single generic measure.
Design Qualitative semistructured interview study, analysed using a framework approach.
Participants and setting Interviews with 31 stakeholders from primary care, secondary care, social care, policy and patient-focused voluntary organisations in England.
Results There was broad support for a single PROM that could be used to measure outcomes for patients with any LTCs in any health or social care setting. Interviewees identified three desired uses for a PROM: to improve the quality of individual care; to increase people's engagement in their own care; and to monitor the performance of services. Interviewees felt that a PROM for LTCs should incorporate a mixture of traditional and non-traditional domains, such as functioning, empowerment and social participation, and be codesigned with patients and professional end-users. Stakeholders emphasised the need for a PROM to be feasible for practical implementation at the individual clinical level as a first priority. A number of concerns and potential problems were identified in relation to the application and interpretation of an LTC PROM.
Conclusions This study has demonstrated support for a single self-report outcome measure that reflects the priorities of people with LTCs, if such a measure can be shown to be meaningful and useful at the individual level. People with LTCs and professional end-users in health and social care should be involved in the development and evaluation of such a measure.
for health services. Psychosocial co-morbidity is associated with poorer quality of life and greater use of health care
in these patients but is often un-diagnosed or inadequately treated in primary care, where most care for these
patients is provided. We developed a brief intervention, delivered by ‘liaison health workers’ (LHWs), to address
psychosocial needs in the context of an integrated approach to physical and mental health. We report a qualitative
study in which we characterize the intervention through the experience of the patients receiving it and examine
how it was incorporated into primary care.
Methods: Qualitative study using patient and practice staff informants. We audio-recorded interviews with 29
patients offered the intervention (three had declined it or withdrawn) and 13 practice staff (GPs, nurses and
administrators). Analysis used a constant comparative approach.
Results: Most patients were enthusiastic about the LHWs, describing the intervention as mobilizing their motivation
for self-management. By contrast with other practitioners, patients experienced the LHWs as addressing their needs
holistically, being guided by patient needs rather than professional agendas, forming individual relationships with
patients and investing in patients and their capacity to change. Practices accommodated and accepted the LHWs,
but positioned them as peripheral to and separate from the priority of physical care.
Conclusions: Despite being a short-term intervention, patients described it as having enduring motivational
benefits. The elements of the intervention that patients described map onto the key features of motivating
interventions described by Self-Determination Theory. We suggest that the LHWs motivated patients to self-management
by: (i) respecting patients’ competence to decide on needs and priorities; (ii) forming relationships with patients as
individuals; and (iii) fostering patients’ sense of autonomy. While truly integrated primary care for patients with
long-term conditions such as COPD remains elusive, existing practice staff might adopt elements of the LHWs’
approach to enhance motivational change in patients with long-term conditions such as COPD.
Keywords: Primary care, Long-term conditions, Qualitative research, Motivational change, Psychosocial intervention
Background
Health outcomes for long-term conditions (LTCs) can be improved by lifestyle, dietary and condition management-related behaviour change. Primary care is an important setting for behaviour change work. Practitioners have identified barriers to this work, but there is little evidence examining practices of behaviour change in primary care consultations and how patients and practitioners perceive these practices.
Objective
To examine how behaviour change is engaged with in primary care consultations for LTCs and investigate how behaviour change is perceived by patients and practitioners.
Design
Multiperspective, longitudinal qualitative research involving six primary health-care practices in England. Consultations between patients with LTCs and health-care practitioners were audio-recorded. Semi-structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re-interviewed 3 months later. Framework analysis was applied to all data.
Participants
Thirty-two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners.
Results
Behaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.
Conclusion
Behaviour change work is often deflected or deferred by practitioners in consultations, who nevertheless vocalize support for its importance in interviews. This discrepancy between practitioners’ accounts and behaviours needs to be addressed within primary health-care organizations.
The role of anxiety in the use of urgent care in people with long term conditions is not fully understood. A systematic review was conducted with meta-analysis to examine the relationship between anxiety and future use of urgent healthcare among individuals with one of four long term conditions: diabetes; coronary heart disease, chronic obstructive pulmonary disease and asthma.
Methods
Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library were conducted These searches were supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts within the field about relevant studies. Studies were eligible for inclusion if they: a) used a standardised measure of anxiety, b) used prospective cohort design, c) included adult patients diagnosed with coronary heart disease (CHD), asthma, diabetes or chronic obstructive pulmonary disease (COPD), d) assessed urgent healthcare use prospectively. Data regarding participants, methodology, and association between anxiety and urgent care use was extracted from studies eligible for inclusion. Odds ratios were calculated for each study and pooled using random effects models.
Results
8 independent studies were identified for inclusion in the meta-analysis, with a total of 28,823 individual patients. Pooled effects indicate that anxiety is not associated with an increase in the use of urgent care (OR = 1.078, p = 0.476), regardless of the type of service, or type of medical condition.
Conclusions
Anxiety is not associated with increased use of urgent care. This finding is in contrast to similar studies which have investigated the role of depression as a risk factor for use of urgent care.
Keywords: Anxiety, Urgent care, Long term conditions, Diabetes' asthma, Chronic obstructive pulmonary disease, Coronary heart disease
We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.
Methods
Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.
Results
Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.
Conclusion
Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of ‘candidacy’ for specific emergency care services, was recursively shaped by previous experiences.
Practice implications
Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients’ judgements of candidacy and their perceptions of accessible expertise in alternative services.
Keywords
Healthcare utilisation; Primary health care; Patient experiences; Qualitative research; Longterm conditions; Unscheduled care; Emergency healthcare; Chronic obstructive pulmonary disease; Asthma; Diabetes; Coronary heart disease; Theory; Candidacy; Recursivity; Patient decision-making"
Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.
Methods
A longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach.
Results
Practitioners view consultations as a means of 'surveillance' of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the 'review' were subsumed to meet the patient's needs, focused on cancer and bereavement.
Conclusions
Routine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients' expectations of future care and socialize patients into becoming passive subjects of 'surveillance'. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.
Aim: We explored Health Care Professionals’ (HCPs) understandings of why patients with LTCs use UC, and the HCPs’ understanding of their role in relation to reducing UC use.
Design and setting: Qualitative study interviewing different types of HCP providing primary care or UC services in Northwest England.
Method: Semi-structured interviews conducted with 29 HCPs (six GPs; five out-of-hours GPs; four emergency department Doctors; two Practice Nurses; three Specialist Nurses; two District Nurses; seven Active Case Managers). Data analysed using framework analysis.
Results: HCPs viewed UC use as a necessary component of care for patients with LTCs. Those whose roles involved working to targets to reduce UC use described a tension between this and delivering optimum patient care. Three approaches to reducing UC were described: optimising the system; negotiating the system; and optimising the patient.
Conclusion: Current policy to reduce UC use does not take account of the perceptions of the HCPs who are expected to implement them. Lipsky’s theory of street-level bureaucrats provides a framework to understand how HCPs respond to imposed policies. HCPs did not see UC use as a problem and there was limited commitment to the policy targets. Therefore policy should aim for whole system change rather than reliance on individual HCPs to make changes in their practice.
"
Method: Interpretative phenomenological analysis was applied to 13 interviews with service users following hospital attendance, and 7 follow-up interviews conducted three months later.
Results: Few participants had a clear understanding of assessment's purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialize, this reinforced hopelessness and promoted disengagement from services.
Limitations: The study sample was small and the participants heterogeneous in terms of self-harm history, method and intent, which may limit the transferability of the findings to other settings. Only self-report data on clinical diagnosis was collected.
Conclusions: This was the first study to utilize an in-depth qualitative approach to investigate service user experiences of assessment and follow-up. The findings suggest that re-conceptualizing psychosocial assessment as primarily an opportunity to engage service users therapeutically may consequently affect how health services are perceived. In order to maintain benefits established during the hospital experience, follow-up needs to be timely and integrated with assessment.
Few qualitative papers specifically address UC in patients in these disease groups. Therefore our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to health care use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011 we identified 43 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. Review conducted between Spring 2009 and April 2011, with a further search December 2011.
Most papers reported on asthma (n=14) or on multiple or unspecified conditions (n=12). The most common methods reported were interviews (n=33) and focus groups (n=14) and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the ‘problem’ of UC, and health care, use in general, decontextualised from the lives of the patients using it.
Patients’ use of UC emerged as understandable, rational responses to pressing clinical need in situations where patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.
Objective
We investigated the views of service users and staff regarding contact-based interventions (e.g., letters, telephone calls or crisis cards) following self-harm.
Method
Self-harm patients recently discharged from an emergency department were selected using purposive sampling (n=11). Clinical staff from relevant service areas and voluntary staff took part in a focus group and individual interviews (n=10). Interviews were transcribed and thematic analyses were conducted using methods of constant comparison to ensure that emergent themes remained grounded in the data.
Results
Most service users and staff participants identified the period of time directly after discharge as the time of greatest need. A contact-based intervention was viewed by service users as a gesture of caring, which counteracted feelings of loneliness. Delivery by mental health specialists was preferred, initially by phone, but letters were considered helpful later. The intervention should be both genuine in delivery and linked to current services. Potential barriers included means of accessing the service and threats to privacy.
Conclusion
The findings suggest that an appropriate design for an intervention might be the provision of an information leaflet, telephone calls (soon after discharge), then letters (offering continuity of contact). Aspects of value and concern expressed by service users should be helpful to clinicians and service providers.
This paper aims to contribute to debates around researcher reflexivity by addressing the interpersonal aspects of interviewing both men and women who have self-harmed or attempted suicide. It is argued that Gadamer’s “fusion of horizons” is a useful concept for the IPA researcher as it encapsulates the fluctuating nature of personal positioning within the research: as we come towards an understanding of the participant, our past and present fuse and change our capacity to understand. In addition, it is argued that this process of reflection during data collection is the start of the analytic process, as our in/ability to connect and moments of fusion and fission with each individual highlight areas of preconception which need to be accounted for during analysis.
A multi-perspective, longitudinal qualitative study involving six primary health-care practices in England was conducted. Consultations between patients with LTCs and health-care practitioners were audio-recorded. Semi-structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re-interviewed 3 months later. Framework analysis was applied to all data.
Thirty-two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners (5 GPs, and 5 practice nurses) took part. Behaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.
The implications of this discrepancy between practitioners’ accounts and behaviours for both primary care practice and the care of people with LTCs will be discussed.
We adopted a multi-perspective, longitudinal qualitative design. With consent, we audio-recorded 26 review consultations across 6 general practices in North-West England. Using tape-assisted recall, we interviewed 20 patients, 5 GPs and 5 practice nurses about their consultations, re-interviewing patients three months later. Patients with one or more of four QOF LTCs were included: asthma, chronic obstructive pulmonary disease, diabetes, and coronary heart disease. Data was analysed using an integrative framework approach.
Despite practitioners emphasising the importance of behavioural change work, and positioning themselves as performing this work in the interviews, there was little evidence of explicit behavioural change techniques within consultations, beyond that of information-giving. Patients experienced reviews as practitioner-led and limited in scope.
Rather than actively engaging patients in change, practitioners avoid direct challenges to patient behaviour, suggesting that it impairs compliance with reviews. By conforming to target-driven care, reviews limit practitioner engagement with, and expectations of, patients’ capacity to change. This rhetoric-practice divergence highlights tensions around co-existing interpretations of what constitutes ‘quality’ patient-focused care that carries implications for the implementation of effective self-management for chronic illnesses.
Disclaimer: This abstract presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10162). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
The CHOICE (Choosing Health Options for Chronic Care Emergencies) Programme is a 5 year NIHR-funded programme grant based in the NHS Manchester area, which aims to develop strategies to improve care for people with chronic illnesses whilst reducing the need for emergency healthcare use. It was hypothesised that psychological co-morbidities, such as anxiety and depression, would predict higher rates of emergency healthcare use in people with chronic illnesses.
CHOICE has involved an extensive programme of both qualitative and quantitative research. After a scoping review phase, and an active research phase, involving both a longitudinal cohort study of predictors of healthcare use and two qualitative research studies, the programme has now entered its third and final phase. This final phase involves implementing a cluster-randomised controlled trial of a complex intervention for people with chronic obstructive pulmonary disease (COPD) based in primary care. In this talk, we will:
· Outline how the qualitative research has contributed to the intervention design process and the role it will play in evaluating the intervention
· Critically reflect on the challenges of carrying out qualitative research within a complex interdisciplinary programme grant
· Discuss relevant learning points for similar healthcare research
This qualitative study forms part of an NIHR-funded research programme. It investigates the role of routine reviews in shaping patients’ healthcare use over time. Research is ongoing (August 2012).
Methods: Patients with asthma, coronary heart disease, chronic obstructive pulmonary disease, and/or diabetes were recruited from GP practices in NW England. Consultations between consenting patients and healthcare practitioners (HCPs) were audio-recorded. Patients and HCPs were interviewed using tape-assisted recall. Patients were re-interviewed after three months. Interviews and consultations were transcribed verbatim. Data was analysed using an integrative framework approach.
Results: 20 routine reviews have been audio-recorded. Interviews have been completed with 26 patients and 6 HCPs (2 GPs; 4 practice nurses). Interim analyses reveal a discrepancy between what HCPs believe reviews are achieving, and how patients respond to reviews. HCPs describe using reviews to engage patients in behaviour change. Patients describe reviews as practitioner-led, and feel unable to raise concerns about their condition. In content, reviews were typically retrospective, and focused on biomedical care. Over time, routine reviews did not seem to influence patients’ healthcare use or behaviour.
Conclusions: Reviews are failing to effect change as patients view them as retrospective and practitioner-led. HCPs should incorporate deliberate strategies to engage patients in raising concerns around living with LTCs, as this can open up opportunities to effect behavioural change.
This abstract presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10162). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Methods: Qualitative study conducted as part of a 5-year UK NIHR-funded research programme CHOICE (Choosing Health Options in Chronic Care Emergencies). Patients were purposively sampled from those participating in a cohort study and were identified from disease registers at 12 general practices in an area of NW England. 50 semi-structured interviews were carried out with consenting patients with one or more of: asthma, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and diabetes. Family were recruited through patients, and practitioners were recruited from various sites, including hospitals, out-of-hours services, and GP practices. Interviews were recorded and transcribed verbatim. Data were analysed using the framework approach.
Results: Patients tended to position themselves as passive with regards decision-making around UC, either responding to urgent need, or following direction from family or practitioners. Family typically took on the role of arbiter, determining level and urgency of need, and viewing chronic illness as a shared burden and responsibility. Practitioners recognised a policy pressure to reduce UC, but varied in their views about responsibility for decisions to use UC. Variation related to the practitioners’ role in provision of care.
Discussion: Whilst policy focuses on the patient as agent of UC decisions, this study highlights that decisions are often shared with or delegated to family and practitioners. Any intervention to reduce UC use would need to account for individual, social and systemic factors that are influencing these decisions.
Disclaimer: This abstract presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10162). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Methods: Patients recruited from those participating in a cohort study in CHOICE and identified from disease registers at 12 practices in one PCT in NW England. Semi-structured interviews with consenting patients with one or more of the long-term conditions: asthma, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and diabetes. Interviews recorded and transcribed verbatim. Data analysed using framework approach.
Results: 45 interviews have been conducted. Initial analysis suggests that patients, faced with a perceived health crisis, seek UC based on the value and meanings that they attribute to available, and previously experienced, services. In particular, many respondents, faced by what they experience as life-threatening crises, see hospitals as places offering safety associated with technology and attentive staff. For some, primary care is not considered a key player in responding to crises.
Conclusions: The meanings and value attributed to secondary care and the limited role the GP is seen to play in managing health crises contrasts with current policy initiatives. A single intervention is unlikely to be appropriate to reduce UC in people with long term conditions. A multifaceted intervention will need to include reducing the health crises that prompt UC, influencing patients' expectations and experience of secondary care, primary care and self-management in responding to these crises and modifications to the care pathways that patients have to negotiate. Tensions between health policy and patients' perceived needs will be discussed.
Disclaimer: This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10162). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
This study aimed to investigate the experience of psychosocial assessment at the emergency department following self-harm. In-depth semi-structured interviews were conducted with 13 people who had recently attended an urban hospital. Interviews were digitally recorded, transcribed and analysed using interpretative phenomenological analysis.
Themes emerging from the interviews included: impact on the self (struggling to understand, failing the self); the hospital environment (feeling safe/unsafe, toll of waiting) and the experience of assessment (feeling judged, struggle to be heard, being legitimated, being understood).
To conclude, needing to seek help after self-harm can impact on an individual’s sense of self and self-esteem, which in turn influences their experience and expectations of services. Patients valued the opportunity to be heard and understood by staff, and struggled with perceptions of being judged or devalued in the hospital.