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Successful Grants 2005-2009 3. A comparative study of the construction and implementation of patient choice policies in the UK |
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1. Improving consumer communication during consultations for non-prescription medicines in community pharmaciesAims: The aims of this project were to explore consumers’ perceptions of non-prescription medicines (NPMs) and providing information to medicine counter assistants (MCAs) during consultations for NPMs.Project outline/methodology: The study was conducted in two stages: elicitation interviews; and, a national survey. The interviews and survey were structured using the Theory of Planned Behaviour (TPB). Interviews were conducted with consumers who had purchased a NPM in one of nine community pharmacies included in the study. The interviews explored consumers’ beliefs and attitudes about two behaviours: buying NPMs; and, giving information to MCAs during these consultations. The interview results were used to develop a questionnaire. The purpose of the questionnaire was to quantify the extent to which the beliefs and attitudes identified in the interviews were held by the general population, as well as to identify TPB variables that could predict intention and self-reported behaviour. The original plan had been to send one questionnaire to 3000 recipients. Due to difficulties with response rates during piloting, two short versions of the questionnaire were sent to 1500 recipients each. The two versions differed in two sections only, with one version including the full TPB questions for buying NPMs and the other containing the full TPB questions for giving information. Key Results: Thirty consumers were interviewed. The total response rate across both questionnaires was 32.7% (955/2924). The common sections and items in both versions of the questionnaire were combined and analysed together. Buying NPMs: The results for the TPB association with buying NPMs showed that intention to buy a NPM in general was driven by attitude toward the behaviour and not by perceived control over the behaviour. People who had purchased NPMs had stronger intentions to purchase NPMs. Recent purchasers had more favourable attitudes but this was associated with the behaviour via intentions, not directly. Giving Information: The results for the TPB association with giving information to MCAs demonstrated that intention to give information to MCAs was driven by subjective norm and perceived control over the behaviour and not by attitude toward the behaviour. People who reported giving information to MCAs while purchasing NPMs had stronger intentions to give information. They also reported stronger pressure to conform to the views of others who were in favour of giving information, but this view related to their actual behaviour via their intentions. Conclusions: Consumers had positive beliefs, attitudes, perceptions of control and intentions towards the purchase of NPMs and provision of information to MCAs. Future interventions to influence the appropriate purchase of NPMs should target subjective norms and perceived behavioural control (i.e. enhance facilitators and reduce barriers). Interventions to promote information provision to MCAs should target subjective norms and intention to give information |
Margaret Watson Marie Johnston Christine Bond Vikki Entwistle Amanda Lee
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Aberdeen SDHI |
CSO |
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2. A review of strategies to promote involvement, a study to explore patient's views and attitudes and a pilot study to evaluate the acceptability of selected patient involvement strategies
There is little research to inform the growing interest in involving patients in healthcare safety initiatives. The research will develop a conceptual framework of ways in which patients might be involved in promoting patient safety. The resulting typology will help organise the findings from extensive reviews of the literature and primary research. Reviews will explore the extent to which patients have been involved in safety schemes, their experiences and any data on their impact. They will also assess what is known about patients’ knowledge of safety issues and their willingness to be involved. Primary qualitative research will add further information on this from a UK context. Individual interviews followed by focus groups will be conducted with patients/carers with one of five conditions (adults with type 2 diabetes, women with breast cancer, children hospitalised for asthma, adults with severe and enduring mental illness, and people having joint replacement surgery) and also a group who have made complaints about their care, all recruited through routine records and via consumer organisations. Finally one promising approach to involving patients will be further developed and implemented in a pilot by a collaboration of patients and professionals. This will be evaluated to explore the feasibility, acceptability and potential impact on safety and costs. |
Ian Watt Vikki Entwistle Y Birks Brian Williams T Sheldon J Glanville J Wright |
York SDHI |
Dept of Health |
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3. A comparative study of the construction and implementation of patient choice policies in the UK
Choice in public services has been developed by governments to meet individual needs with more responsive services, to challenge the power of professionals, to drive quality improvements and to improve equity as well as being seen as a good thing in its own right. However, the focus of choice policies does differ across the UK. The increasing divergence of the NHS systems within the UK since devolution has, however, created a natural laboratory and comparison between the constituent countries of the UK provides a unique opportunity to examine policy differences and their consequences. The aim of this proposal is to identify the content, operationalisation and effects of the different policies in respect of patient choice in the four home countries and assess their impact on health system performance, including responsiveness to patients. Objectives of the project to identify how choice policies are constructed, how they are implemented and what the impacts of patient choice are on health systems and patients. IN particular we will examine how the construction of choice policies, patterns of service provision, the interaction of different choices (types of treatment and location/provider of treatment) and local operational issues and patient circumstances structure the actual choices that patients can make. The study will utilise a multi level approach, combining comparative case studies with interviews and documentary analysis to provide a comprehensive analysis of the different choice regimes and operation and impact of choice policies in health care within the UK. This approach will ensure that different perspectives and the impact of policy and organisational contexts are taken into account while ensuring methodological rigour through researcher and data triangulation. The research will involve:
The comparative nature of the research will allow us to provide a detailed analysis of the construction, provision of patient choice across the UK providing lessons for policy makers, managers and patient organisations. As such dissemination will involve developing a project website and e-newsletter, academic and non-academic reports and articles, workshops and conferences as well as SDO briefings and a report. |
Stephen Peckham Pauline Allen Nicholas Mays David Hughes Lesley Griffiths Huw Davies Vikki Entwistle Andy Thompson Leslie Prior |
LSHTM Edinburgh |
SDO
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4. The multiple and shifting emphases of quality initiatives in primary care: a preliminary qualitative investigation of GPs' views Understandings of what constitutes ‘good’ medical practice are continually evolving. This has important implications for the demands placed on doctors, but there have been few studies of GPs’ experiences of shifting quality agendas and contemporary quality improvement initiatives. Most of the research that has been conducted has been designed primarily to inform efforts to change GPs’ behaviour in particular ways. There is a strong case for taking a more critical look at the values that are expressed in contemporary health policies or implicit within current initiatives, and for careful examination of health professionals’ responses to and experiences of these. This study focuses on the concepts of evidence based medicine (EBM), patient involvement in decision−making (PI) and support for self−management among people with chronic conditions (SSM). These are now widely associated with good quality health care, but they have been variously defined and it is not clear exactly what they entail or how they might be recognized – especially in general practice. There is also uncertainty about how the concepts relate to each other, and about the compatibility and value of different strategies to promote them. Current policy initiatives that aim to improve the quality of health care include efforts to ensure that particular aspects of practice reflect dominant interpretations of the implications of clinical epidemiological evidence about the effects (and sometimes costs) of different interventions. Clinical guidelines and performance assessment schemes tend to encourage a standardization of care. At the same time, health professionals are encouraged to respect the potentially differing needs and preferences of individual patients – and thus to individualise care. Very little is known about GPs’ experiences of being asked to facilitate PI and offer SSM in contexts in which their own performance is increasingly assessed in terms of the specific preventive or therapeutic interventions that they deliver and the biomedical status of their patients. In these contexts,patients who choose options that are sub−optimal for certain aspects of health may leave GPs vulnerable to being judged not to have delivered good quality care.It thus seems timely to investigate in more detail contemporary GPs’ views about what matters for healthcare quality, and their experiences of policy initiatives that aim to promote EBM, PI and SSM. The qualitative study will involve approximately 20 in−depth face−to−face interviews with GPs working in NHS Tayside, and another 20 in-depth face-to-face interviews with GPs working in New South Wales, Australia. We will seek to include both male and female GPs who have been working in practice for different lengths of time and whose practices serve more and less affluent areas. We will also seek to include GPs who do and do not specialise in the care of people with diabetes and/or heart disease. Interviews will be conducted in an open conversational style will be used and questions will cover the following topics in detail:
Treatment Decision Making' (PI), 'Support for Self Management' (SSM) and the relationships between them;
implications for different aspects of quality. A ‘Framework’ approach (Richie & Lewis 2003) will be adopted to ensure the analysis is developed systematically and can be discussed among team members. Analysis will start soon after the first few interviews to ensure that unanticipated emergent issues of interest are adequately explored in later interviews. The analytic process will involve: familiarization with early transcripts; development anddiscussion of a preliminary list of topics and issues of interest; coding of transcripts to reflect topics and issues of interest; development of data summary charts; discussion of emerging findings among the projectteam and identification of issues for further exploration; refinement of topic/issue codes as appropriate, followed by systematic recoding of all transcripts and further development of data summary charts; careful checking for data/cases that do not fit emergent findings and refinement of findings categories or emergent hypotheses as appropriate. |
Vikki Entwistle Penny Lockwood Ian Watt Lyndal Trevena
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SDHI York Sydney |
East Renfrewshire Research Bursary |
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5. What health care experiences matter to patients and how can we assign value to them for policy making purposes?
Many aspects of health care experience are important to patients, and for reasons beyond their impact on health. This suggests that health state outcomes should not be the only factors considered in evaluations of health care interventions and services. However, policy recommendations about resource use are often based primarily on information about health state outcomes and costs. Our proposed research will inform decisions about the use and future development of techniques for valuing patient experience factors to inform policy. It will address the following questions: Question 1. What aspects of health care experience other than health state outcomes matter to people and why? Question 2. To which patient experience factors do policy makers need to be able to attach quantitative estimates of worth? Question 3. What methods are currently available for assigning quantitative estimates of worth to patient experience factors, and what is their methodological status? Question 4. What values do rigorous valuation techniques generate for key patient experience factors? Question 5. What additional research is needed to help policy makers reflect patient experience factors more routinely in their decision making? The project will have two main stages. Stage 1 will address questions 1 and 2 above, using an interpretive synthesis of existing literature and a workshop to develop and refine a conceptual map of patient experience factors. Stage 2 will address questions 3, 4 and 5 using a methodological review and workshop, followed by a systematic review of applications of rigorous valuation techniques to populate the conceptual map. |
Mandy Ryan Vikki Entwistle Jill Francis Cynthia Fraser Helen Tyrell
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Aberdeen SDHI |
NIHR |
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