(1) Modelling phase
The main barriers facing staff and patients in delivering and receiving secondary prevention and how the intervention would fit in with their current activities were identified within the themes:
- Time and money
- Training
- Motivation
- Health beliefs
Most of the themes include quotations from staff and patients from both NI and the RoI that exemplify differences and similarities in their views and experiences as a result of their living in two different healthcare systems. The quotations were also chosen to include the diverse views and experiences of GPs, nursing and administrative staff.
Time and money
Practice staff in both healthcare systems identified lack of time and money as major barriers to delivering secondary prevention. However, RoI GPs complained more about financial insecurity. They relied for their income on a mixture of public and private finances (see Figure 1) and considered that the level of public funding for secondary prevention for GMS patients was inadequate. Staff also reported embarrassment in asking privately-funded non-GMS patients to pay for extra visits for preventive care and were conscious that some non-GMS patients perceived these visits as opportunities for them to make more money. It appeared that mechanisms of payment for services could influence decisions to invite patients for review and impact on the doctor-patient relationship.
'Our GMS contract doesn't allow us to do prevention...if we raise the issue and do it properly the amount of time and effort...it's financially disastrous.' (Practice 1, GP2)
'The private patient thinks that you're bringing them back too often to make money out of them.' (Practice 1, GP2)
'It's kind of embarrassing when they go, "but sure I was told to come back for that".' (Practice 1, practice manager)
Arrangements for payment also influenced patients' readiness to attend. Their perceptions of the value of preventive healthcare varied with some patients more willing to pay for preventive healthcare than others. Various comments indicated the balance that existed in decisions to uptake services. Healthcare costs were considered in competition with other living expenses with some patients disagreeing that preventive healthcare provided value for money.
'Your health is your wealth.' (Practice 1, female patient 3)
'I would feel bad and I still wouldn't go to the doctor...I have a lot of little holes for the money.' (Practice 1, male patient 2)
In contrast to these reports from the RoI, the influence of financial cost was not recognised by NI patients, all of whom received free prescriptions. Also, NI staff tended to disregard any financial loss associated with providing secondary prevention.
'It's not particularly well recompensed...none of the extra clinics currently are in general practice... they cost a lot more to run than we actually get for them... it's just because we think that it's a good service to offer to our patients.' (Practice 4, GP1)
Training
In both systems staff identified how updating their knowledge would improve their confidence in prescribing. They were aware of a need for training, specifically in relation to prescribing and behaviour change, which should include evidence to support their clinical activity.
'specific training has to be given on the different issues like management of cholesterol...so that...you're...comfortable enough that you change what has been done in the hospital' (Practice 1, GP1)
'They haven't tried so why should we be wasting our energy on this person?' (Practice 1, GP2)
'For sometimes you can get a wee bit frustrated...if people don't come in you think...what's the point of this?' (Practice 4, practice nurse)
Lack of time and money led staff to emphasize that training should be short, focused and integrated into practice timetables. Attending training sessions outside of practice premises or lasting more than two hours were not acceptable options.
'It has to be very relevant to what you want to do...I think you're going to have to be very focused' (Practice 4, GP2)
'Getting down to the basics awful quickly...everything in the shortest possible time...I would not go for a 2 day course...2 hours' (Practice 1, GP2)
Motivation
Staff considered that poor motivation to comply with secondary preventive advice was reflected in patients' non-attendance at appointments. They attributed it particularly to those who lived in socio-economically deprived areas in both healthcare systems. However, they also identified that patients in employment had difficulties attending during surgery hours because of financial implications of taking time off work and they expressed a reluctance to ask patients to take time off work to attend appointments.
'There are people who genuinely feel that they can't afford to take time off work to come to us during our surgery time.' (Practice 3, practice nurse)
'I'm very conscious of asking them to take time off work' (Practice 2, practice nurse)
Recognition of these influences led to staff tailoring their services for patients. However, they also recognised the possibility of creating a culture of dependency, characterised by RoI staff to be more common among GMS than non-GMS patients. The inter-play of State funding of healthcare and personal responsibility was considered to influence both the provision and uptake of care.
'Give them the information and show them how to manage things themselves... you'll get away with that with the private patient...whereas the GMS patient isn't used to doing that because he likes somebody to take care of everything for him.' (Practice 1, GP1)
Health beliefs
Patients, particularly those living in socio-economically deprived urban areas, in both systems, emphasised their beliefs relating to the role of stress in causing their heart condition. The perception of a behaviour change having possible adverse effects on their stress levels influenced their compliance with advice.
'Smoking did contribute to it but it wasn't the main factor, no way, it was stress...doing away with the stress means an awful lot more to me than doing away with those two cigarettes.' (Practice 2, female patient 1)
'..that half hour with a glass of sherry and a cigarette and the crossword is as important...as going for a walk.' (Practice 1, female patient 4)
They reported internal stress in knowing that they should take exercise but feeling physically unable to do so. Some feared their heart condition would deteriorate if they exercised and criticised how current service provision did not deal adequately with reducing their stress or tackling their fears.
'I was told to exercise and start walking...I couldn't do it, I was absolutely shattered so that was making me more stressful.' (Practice 3, female patient 2)
'...more important than your body is your...state of mind...there's not enough dealing with what goes on in your head.' (Practice 2, female patient 2)
(2) Exploratory phase
The findings were used in tailoring the intervention to address the barriers, described above, to make it applicable to each particular setting within both healthcare systems. The experiences of staff and patients in delivering and receiving this intervention, its perceived effects on motivation and lifestyle changes, the usefulness of the patient information booklet and the value of the training delivered were explored. Their experiences of the intervention are presented within the same themes as those already identified as barriers to the uptake and delivery of secondary prevention.
Time and money
All staff members approved of the financial recognition provided for practices in both systems and that no patients were charged for visits. In respect of the differing funding arrangements in NI and RoI patient reviews were integrated differently into existing programmes. In NI nurses, doctors and receptionists liaised within each practice to ensure that patients were not called within short time intervals to attend different clinics where similar assessments were made. In the RoI integration with Heartwatch aimed to minimize additional practice administration. However, this proved unsuccessful as staff and patients were unclear about the difference between Heartwatch and the intervention.
'There is a lot of cross-over between the two...we already seemed to be doing a lot of it anyway.' (Practice 1, GP)
In all but one of the practices administration of the intervention was delegated to the practice nurses. With the exception of one practice nurse who had been allocated protected time for the study, they all found administration of the intervention time-consuming because of their busy workloads. Despite efforts to minimize it, they resented the extra time they had to spend on record-keeping and paperwork.
'... it is good. It's just the initial workload.' (Practice 3, practice nurse)
Training
Staff criticized the behaviour change training for being too theoretical and not giving enough emphasis to the practicalities of implementing it. They recommended that opportunities to watch a consultation and to practise what they learned in 'role play', should be included.
'... it would have been quite useful...for me to actually watch a consultation...that might have made it more hands on and then I would have known I was doing it right.' (Practice 2, practice nurse)
'Just to make that jump from theory to practice.' (Practice 1, GP 1)
Staff responded positively to the medication training; they appreciated opportunities for case-based learning.
'that particular group thing...... was very good.' (Practice 2, practice nurse)
Motivation
The intervention was designed to tailor consultations to patients' socio-economic circumstances and health beliefs. Staff reported that in doing so they became more knowledgeable about their patients and were able to personalise lifestyle advice. They were encouraged by patients' positive responses to advice but found difficulty motivating 'model patients' who had already 'healthy' lifestyles and older people who felt it was too late in life to make significant changes.
'...saw some of the positive effects of it .........really personalising it and looking at where they are and where they're coming from.' (Practice 4, practice nurse)
'...... model patients. So that was one of the issues, trying to identify an area for them to work on.' (Practice 1, GP)
Patients valued the information given in the booklet about heart disease, lifestyle change and medication. However, they were reluctant to complete the self-monitoring pages within it, relating to lifestyle change: they considered this was unhelpful.
'I know in my head what I have to do, so I don't need to run to the book all the time.' (Practice 4, male patient 1)
'...trying to fill that smoking bit in everyday would put the cigarettes in my mind.' (Practice 3, female patient 2)
Patients found it difficult to identify specific goals in relation to lifestyle behaviours, particularly stress. Staff also questioned the practicalities of setting goals in relation to stress management.
'It's one of those things you don't see or you can't hear or feel, you can't tell a doctor or anybody how stressed you are...it's a very personal thing, you can't describe it and another person can't relate to how you feel.' (Practice 2, male patient 1)
'I just don't know how practical it is, I mean a stress self-monitoring form, yeah, I'd be interested to see how many people actually do fill that in.' (Practice 1, GP)
Some staff used the booklet in consultations as a prompt to remind them of relevant issues but others felt that it obstructed the flow of individual consultations. They cautioned against relying on it for recording patients' progress since many failed to bring it to review consultations.
Application of findings to intervention design
The implications of financial costs for both staff and patients in the RoI identified in the modelling phase had not been reported previously and it was important to address these within the development of a structured system to promote arrangement of and attendance at review appointments. In keeping with previous studies [12, 21, 22] training needs and time constraints identified by staff informed design of a training programme (similar for both systems) and administrative elements of the intervention (different details for different systems and practices). Patients' reports of the importance of stress within their health beliefs were addressed in an information booklet.
The qualitative data from the exploratory phase led to the intervention being adapted for the main trial. Although we had considered, within the exploratory phase, that we had minimised administrative elements of the intervention, resentment among staff of the time required for administration resulted in the paperwork and overall administrative load being reduced. The confusion caused by integrating the intervention with the initiative Heartwatch (RoI) [16] led to the decision to exclude Heartwatch practices. Flexibility in tailoring structured recall programmes to practices' needs was increased. Patient information was amended to increase examples of goal setting for behaviour change and omit self-monitoring records. The qualitative research highlighted the need for the training and the approach to behaviour change to be considered within specified theoretical frameworks which addressed aspects of patient and staff motivation, and patient health beliefs using practical examples of application of theory and case-based learning. A full discussion of the behaviour change theories relevant to the intervention has already been reported [23].