How QOF is shaping primary care review consultations: a longitudinal qualitative study

被引:58
|
作者
Chew-Graham, Carolyn A. [1 ,2 ,3 ]
Hunter, Cheryl [4 ]
Langer, Susanne [5 ]
Stenhoff, Alexandra [6 ]
Drinkwater, Jessica [2 ,3 ]
Guthrie, Elspeth A. [7 ]
Salmon, Peter [8 ]
机构
[1] Keele Univ, Res Inst, Keele ST5 5BG, Staffs, England
[2] Univ Manchester, Primary Care Ctr, Inst Populat Hlth, Manchester M13 9PL, Lancs, England
[3] Univ Manchester, Natl Sch Primary Care Res, Manchester M13 9PL, Lancs, England
[4] Univ Oxford, Nuffield Dept Populat Hlth, Hlth Serv Res Unit, Oxford OX3 7LF, England
[5] Univ Liverpool, Dept Mental & Behav Hlth Sci, Liverpool L69 3GB, Merseyside, England
[6] Univ Liverpool, Inst Psychol Hlth & Soc, Dept Mental & Behav Hlth Sci, Liverpool L69 3GB, Merseyside, England
[7] Manchester Royal Infirm, Manchester M13 9WL, Lancs, England
[8] Univ Liverpool, Inst Psychol Hlth & Soc, Div Clin Psychol, Liverpool L69 3GB, Merseyside, England
基金
美国国家卫生研究院;
关键词
Primary care; Long-term conditions; Quality and Outcomes Framework (QOF); Consultations; Longitudinal qualitative research; PATIENT-CENTERED CARE; GENERAL-PRACTICE; FINANCIAL INCENTIVES; HEALTH-CARE; CONSEQUENCES; OUTCOMES; PAY;
D O I
10.1186/1471-2296-14-103
中图分类号
R1 [预防医学、卫生学];
学科分类号
1004 ; 120402 ;
摘要
Background: 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.
引用
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页数:7
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