Weight loss options in general practice

A positive approach, using the 5As, is required when helping obese patients manage their weight

Obesity, defined as a body mass index (BMI) of 30 kg/m2 or more, is increasingly prevalent in Australia, affecting 28% of adults, 7% of children aged 5–17 years and 27% of patients who present to general practice.1,2 Overweight and obesity are strong risk factors for chronic conditions such as diabetes, which have also been steadily increasing over the past two decades.1 Although obesity is ultimately due to an imbalance between energy intake (diet) and expenditure (digestion, metabolism and physical activity), this is influenced by a complex range of other factors, including genetics, epigenetics, the gut biome, the social environment, culture and health literacy over the life cycle.3

In the face of this complexity and repeated failed efforts by their patients to lose weight, many clinicians feel frustrated, attributing the lack of success to lack of patient motivation.4 The negative attitudes of some clinicians, in turn, result in many patients trying to lose weight without medical support.5 Yet, obesity can be addressed successfully and even small amounts of weight loss are associated with lowered cardiovascular risk and delayed onset of chronic conditions such as diabetes.3

The 5As approach provides a useful framework for general practitioners to help obese patients manage their weight and was adopted in the recent National Health and Medical Research Council (NHMRC) clinical management guidelines.3 It involves the following steps:

ask and assess BMI, waist circumference, diet (especially fruit, vegetable and fat intake), physical activity, comorbidities, medications that might contribute to weight gain, and readiness to change
advise on the benefits of a healthy lifestyle and weight management; even small amounts of weight loss (5%) are beneficial
assist by providing (directly or by referral) education on diet, physical activity and behaviour change; a diet that produces an energy deficit of 2500 kJ per day and 300 minutes of moderate-intensity activity or 150 minutes of vigorous activity per week are recommended
- if BMI > 30 kg/m2 with no weight loss, consider a very low energy diet
- if BMI > 40 kg/m2 or > 35 kg/m2 with comorbidities, consider surgery
arrange follow-up and review, to prevent relapse and provide support.

Effective interventions target both diet and physical activity, use established behaviour-change techniques and mobilise social support.6 Fad diets are unhelpful. Low-carbohydrate, high-protein diets can be useful in achieving short-term weight loss but caution is needed because there is evidence of increased long-term cardiovascular risk.7 Very low energy diets using meal replacements can be beneficial but require careful monitoring and support (although meal replacement products are available without a prescription).

Obese patients are not often referred to allied health professionals (eg, dietitians, exercise physiologists and health educators), even though such referrals can help patients achieve and maintain modest weight loss. Education and coaching in diet and physical activity change has been shown to result in 3%–10% weight loss.8,9 There are many different weight loss services and programs run by commercial providers, health clinics, government agencies and non-government organisations. However, not all are evidence based and it can be a challenge for GPs to know which will be effective. Further, many patients fall by the wayside because of cost, availability, transport, and appropriateness for their language, sex or cultural background. Cost can be reduced by using chronic disease management items in the Medicare Benefits Schedule when referring patients who have chronic conditions; these help patients access multidisciplinary care from three providers. It is important to assist patients as they navigate the complexities of the health care system, especially patients with low health literacy.

Currently available medications are not well tolerated and have limited effectiveness in weight maintenance. Orlistat and phentermine are the only weight loss drugs registered for use in Australia. Both are expensive and neither is listed on the Pharmaceutical Benefits Scheme. In this issue of the Journal, Neoh and colleagues10 show that a combination of phentermine and topiramate is poorly tolerated due to adverse effects. A phentermine–topiramate combination was recently approved for use in the United States, although the approved formulation and doses differed from those used in Neoh et al’s study.

Another article in this issue, by Lukas and colleagues,11 adds to the body of evidence showing that surgery is effective in not only achieving weight loss but also in control of comorbidities, especially diabetes.12 The choice of surgical procedure (eg, laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy or Roux-en-Y bypass) should be individualised. Surgery should not be considered a last resort, especially because relatively young patients can benefit. However, surgery is an expensive option for most people (as access to bariatric procedures in the public sector is limited, despite evidence of effectiveness), and surgery is most effective when it is part of a multidisciplinary approach that includes diet, physical activity and psychological support.

Whatever the treatment approach, follow-up is important. This should be frequent: fortnightly for the first 3 months of a weight loss program with review and escalation in intensity if there is less than 1% decrease in weight.

It is not news to GPs that there is no panacea to the obesity epidemic and that other interventions are required early in life and at a population level. However, there is justification for some optimism — modest weight loss and reductions in health risk are possible, and GPs have an important role to play in helping patients manage their weight.

Excessive occupational sitting is not a “safe system of work”: time for doctors to get chatting with patients

Employers and doctors need to recognise and respond
to the health hazards of too much sedentary time

Being able to work usually has a positive impact on health. However, changes in the physical demands of work and increased use of computers have led to many workers now being employed in sedentary jobs.1 While these have traditionally been thought of as safe work environments, recent evidence (including meta-analyses2) suggests this mode of work — often involving long uninterrupted periods of sitting — may be hazardous, contributing substantially to the growing chronic disease burden associated with obesity, diabetes, cardiovascular disease and cancer.3,4 Importantly, being sedentary (ie, too much sitting) is not the same as being physically inactive. Insufficient physical activity is defined in the public health context as not meeting the guidelines to accumulate at least 2.5 to 5 hours of moderate-intensity physical activity per week.5 Both physical inactivity and sedentary time have an impact on health: physical inactivity is estimated to account for 5.5% of all-cause premature mortality, and excessive sitting time, after adjusting for physical activity, accounts for 5.9%.2 Notably, even if workers meet physical activity guidelines (ie, are physically active), they can still have high exposure to sedentary time.

Work health and safety laws in Australia and other jurisdictions require employers to provide a “safe system of work”. For example, section 19 of the Work Health and Safety Act 2011 (Cwlth) states that the “primary duty of care” is to “ensure, so far as is reasonably practicable, the health and safety of workers” by, among other things, “provision and maintenance of safe systems of work”. We contend that: a) the systems of work commonly observed in contemporary offices demonstrate a high likelihood of excessive sitting hazard; b) the degree of harm associated with this hazard is likely to be substantial; c) the evidence for this is now widely known; d) there are available ways to minimise the risk; and e) the cost of these strategies is proportionate to the risk.

Exposure to sedentary time can be substantial for office workers. Objective measurement has found that, on average, over 75% of the office workday is spent sitting, with much of this accumulated in unbroken bouts of at least 30 minutes,3,6,7 demonstrating the hazard is much more common than previously thought.

There is now also evidence that both overall sedentary time and the pattern of sedentary exposure are associated with substantial harm. For example, excessive total sitting time is associated with premature mortality, obesity, cancer (ovarian, endometrial and colon), type 2 diabetes and cardiovascular disease.2–4 Conversely, regular interruption of sedentary time is beneficially associated with biomarkers for chronic conditions.8,9 Occupational exposure can account for around half of total weekly sedentary time,3,7 and thus fractional risk attribution implies occupational responsibility for around half of the harm.

The evidence for the harm associated with excessive sitting is now being widely promoted. The recently updated Australian Government guidelines recommend minimising the time spent in prolonged sitting.5 Further, media stories reported in recent years have highlighted the potential dangers of excessive sitting.10 Advanced organisations are implementing risk control strategies using, for example, a sedentary work practices toolkit.11

Changes to work systems can reduce sedentary time. Alterations to the individual physical environment (eg, sit–stand workstations or active workstations)12,13 and combined approaches (including individual, environmental and organisational changes)6 have achieved substantial reductions in total occupational sitting time and prolonged unbroken sitting time. The extent to which such changes can minimise chronic disease is now being investigated.

Some risk reduction strategies, such as introducing standing meetings, are costless. While other strategies have a cost, the cost does not seem disproportionate given the potential for significant harm (eg, reduced life expectancy and cardiovascular disease).

On the available evidence, it appears that contemporary offices may be failing to provide a safe system of work. Doctors should be prescribing behaviour to reduce occupational sedentary exposure where this may exacerbate, or be exacerbated by, an existing medical condition. A doctor who is aware that a patient has a prolapsed disc in the spine would require the patient to refrain from lifting heavy objects at work. In the same way, a doctor who is aware that a patient’s cardiovascular condition necessitates remaining active and avoiding excessive sedentary exposure should inform the patient and employer of the need for the patient to regularly move to maintain wellbeing. This could be achieved through the redesign of work tasks to enable postural variability or through regular breaks that involve activity such as walking. In addition to raising this matter in routine patient consultations, doctors could be supporting organisations attempting to provide systems of work in which workers “sit less, move more, and move more often”.14

Role of the medical community in detecting and managing child abuse

To the Editor: I thank Oates,1 and Gwee and colleagues2 for writing on the role of the medical community in detecting and managing child abuse. I would like to add to the points they make. Doctors have a crucial role in medical follow-up for children in out-of-home care. Many children in out-of-home placements have complex needs, with physical and mental health disorders.3 Placement breakdowns mean that some children lack consistency in medical follow-up, which can lead to complete treatment drop-out. This is a significant risk factor for children in care.4

Keeping the child health passport up to date can help with handover of medical conditions for children changing placements. General practitioners can assist with handover by keeping a log of prescriptions issued, with photocopies of private scripts.5 A doctor should highlight in the medical record when a patient is a child in care, making note of the name of the person who attends with the child, which organisation he or she works for, and details of the responsible government department and case worker. Such details can be useful to track a new abode for the child, particularly in the context of a missed appointment. Details of the guardian are also valuable when seeking consent for treatment.

Medication safety can be promoted through: carers leaving prescriptions at a designated pharmacy; weekly or fortnightly dispensing; use of Webster-paks; and the safe storage of medications by carers. The medical community can, with documentation and attention to prescribing, assist with the medical management of children in care.

Should general practitioners order troponin tests?

Cardiac troponin I and T are the preferred biomarkers for assessing myocardial injury. Understanding the pathobiology of troponin and the timing of troponin testing is fundamental to the clinical utility of these biomarkers, as troponin and its kinetics are central to the universal definition of acute myocardial infarction (AMI).1 Troponin levels become elevated in serum within a few hours of an AMI, and they remain elevated for up to 7–10 days.2 However, numerous other conditions may elevate troponin levels, so it remains essential that the results of troponin tests be interpreted with clinical findings and electrocardiography results.3 The dynamics of troponin levels (rise and/or fall over time) help distinguish AMI from non-AMI conditions, thus serial troponin testing is the standard approach recommended for assessing patients with suspected acute coronary syndrome (ACS).4 In this article, we explore troponin testing in general practice, including problems faced by laboratories that offer testing in this context.

The absolutist stance

One stance on this topic is that general practitioners should never order a troponin test. The basis of this argument is that the only widely accepted clinical indication for measurement of troponin levels is suspected ACS, which should prompt referral to hospital based on clinical and electrocardiography findings without recourse to troponin testing. Supporting this argument is that serial troponin testing is unrealistic in most general practice settings, and opens the question of how a patient should be monitored while the results are awaited.

One argument against this absolutist stance is that it is an oversimplification. Further investigation and management depends on the degree of suspicion for ACS, and timing of the presentation may obviate the need for serial testing. Chest pain is a challenging symptom and the prevalence of unstable angina or AMI in general practice is low, in the order of fewer than 5% of patients with chest pain.5 Atypical presentations of AMI, such as in young people,6 people with diabetes and older people, are a perennial concern. GPs have been shown to be fairly accurate in assessing chest pain clinically as due to coronary artery disease, but not accurate enough to safely exclude it.7 A system of estimating pretest probability of ACS, or risk of short-term complications, is an attractive approach. Clinical decision-making rules and pretest probability tables have been developed to assist with this process in general practice8,9 and, while some risk stratification tools may be more relevant to doctors in emergency departments, they are potentially useful to GPs.10,11 How troponin testing might fit into risk stratification in general practice is not entirely clear.

How well do GPs understand troponin tests?

Audits from New Zealand suggest that GPs have a generally sufficient understanding of the use of troponin tests in primary care.12,13 Knowledge of false-negative results (eg, due to sampling too soon after symptoms) appears to be better than knowledge of false-positive results (eg, due to non-AMI causes of raised troponin levels). Most GPs would refer high-risk patients without troponin testing, but a small proportion of GPs would defer hospitalisation while waiting for the troponin result (mostly for patients with an intermediate probability of AMI).

Why do GPs request troponin tests?

Our experience suggests that GPs mainly request troponin tests to rule out AMI in one of two situations. The first situation is patients who had symptoms in the preceding days but for whom symptoms have resolved (also the experience of others13,14). One expert has suggested that this may be a justifiable use of troponin testing in primary care15 and troponin testing is suggested in National Institute for Health and Care Excellence (NICE) primary care guidelines in pain-free patients who had chest pain more than 72 hours earlier.9 The second situation is patients who have atypical symptoms and/or a low likelihood of ACS, in whom troponin testing appears to cover the residual clinical uncertainty. Unexpectedly positive troponin results occasionally occur in such situations, which may otherwise not be detected.

How do GPs currently request troponin tests?

Most requests for troponin testing from general practice are requests for a single test, not serial testing.16 This begs the question of whether ordering a single troponin test is an appropriate strategy. Given our understanding of troponin kinetics, a single negative troponin test result a certain time after symptom onset could be clinically useful in ruling out AMI (ie, in “late presenters”). The suggested time frame varies between publications, but is usually in the order of 6–9 hours4,17 with the caveat that the time of symptom onset can be unreliable. Local experts have suggested that a single troponin test 12 hours after resolution of suggestive symptoms (with a normal electrocardiogram and no high-risk features) is useful for this purpose.11 With the so-called high-sensitivity troponin assays, this window may decrease: in an emergency department setting, an undetectable (ie, not merely negative) troponin value obtained from a high-sensitivity troponin assay at presentation has been shown to have a very high negative predictive value for a subsequent diagnosis of AMI,18 but this strategy is experimental. The safest rule of thumb is that a single negative test result for troponin does not exclude AMI in a patient with current or very recent symptoms, nor does it exclude clinically significant coronary artery disease.

Conditions associated with chronic troponin elevation

As most GP requests for troponin testing are for a single test, conditions associated with chronic, non-AMI elevation of troponin levels present a problem. Examples include chronic cardiac failure and chronic kidney disease (CKD). A positive result from a single troponin test could be misleading because it might reflect the underlying chronic disease and not AMI. The prevalence of positive troponin test results (defined as above the 99th percentile of the general population) in CKD depends on the stage of the CKD (positive results are more likely during more advanced stages) and on the troponin assay used. This is exemplified by a recent study of asymptomatic patients who had CKD but were not on dialysis. The prevalence of a positive troponin result (for the whole cohort) was 68% when a high-sensitivity troponin T assay was used, 38% when a high-sensitivity troponin I assay was used, and 16% and 8% for troponin T and I, respectively, when contemporary (“less sensitive”) assays were used.19 Despite the high rates of positive troponin results in this study, a negative troponin result from a sample taken at an appropriate time is useful for ruling out AMI in patients who have CKD, but at the considerable disadvantage of reduced positive predictive value, with the attendant risk of unnecessary hospitalisation. Clinical assessment of the acute event in such patients becomes all the more important if this is to be avoided.

Logistics of troponin testing for outpatients

Offering troponin testing in the community is logistically complex and there is a lack of formal guidance for laboratories in this area. Guidelines on management of ACS recommend that a troponin test result should be available within 60 minutes of blood being drawn and, if not, that point-of-care testing should be available.4 This is aimed at hospital-based laboratories and is not a realistic target for large private pathology networks that may test hundreds of community samples per day at variable geographical distances from large networks of collection centres and general practices. So what is the solution? Accept the longer turnaround times and promote judicious use of troponin tests by GPs? Longer turnaround times may be acceptable if testing is largely confined to patients who have a low pretest probability, or low risk, of AMI. If so, what is a reasonable turnaround time for community samples — three hours? Six? At the other extreme is rigorous pursuit of fast turnaround times to meet the apparent clinical need in the community, probably with the help of point-of-care testing, although there are questions about the performance of point-of-care troponin assays.20 The solution is probably a compromise between the two. The only guidelines that provide advice on this are the NICE guidelines, which state that troponin testing can be undertaken in general practice “providing timely results can be obtained” but do not elaborate on what “timely” means.9

After-hours elevated troponin levels can be problematic for all concerned. For example, when samples are taken late in the afternoon, results might not be available until after clinic hours. A common policy is to treat positive troponin test results as “critical results” and to notify the requesting doctor or a representative (such as a locum GP service, if nominated). In the event that a doctor cannot be found to take the result, which is not uncommon in our experience, laboratory staff (usually pathologists) phone patients directly and advise that hospitalisation is the safest course of action. But when a patient cannot be contacted, laboratory staff face a dilemma: can the result wait until office hours, or should emergency services be arranged? We are aware of anecdotal cases in which after-hours notifications of high troponin levels to patients at home have probably contributed to their early survival — but this raises the question of whether such patients are better served by referral to hospital in the first instance. A published coroner’s case touches on these important issues for both GPs and pathologists.21

Conclusion

We suggest that GPs should have a high threshold for requesting troponin testing and carefully assess risk before ordering troponin tests. Positive troponin test results usually change the course of management, but the time frame in which the result becomes available must be balanced against the risk of delay in diagnosis and therapy. A troponin test should not be requested unless a GP is certain that a robust process is in place by which they can be contacted, day or night, if the result is positive. There is an obvious need for further education, research and inclusion of this topic in future clinical guidelines. Our suggestions for using, or not using, troponin tests in general practice are summarised in the Box.

Suggestions for using, or not using, troponin tests in general practice

The default position

The default position for patients who have symptoms suggestive of acute coronary syndrome is hospitalisation without prior troponin testing.

Using a single troponin test

It is reasonable to use a single troponin test in general practice to exclude the possibility of acute myocardial infarction (AMI) in asymptomatic patients whose symptoms (typical or otherwise) resolved at least 12 hours prior, so long as they have no high-risk features and a normal electrocardiogram.11
A single troponin test may also be useful to investigate an otherwise unexplained creatine kinase elevation.

Using serial troponin tests

In patients presenting to general practice within 12 hours of symptom onset who are at low risk of AMI and/or have atypical symptoms, and for whom troponin testing is being considered, serial testing is advised.
In patients with conditions that are associated with a high prevalence of positive troponin test results, such as chronic kidney disease, a single test can be misleading. Serial testing may be required to resolve clinical uncertainty.
Serial testing is most appropriately performed in hospital. The safety of serial testing in outpatient settings has not been established.

The path to healthy communities – from data to delivery

Strong primary health care is the cornerstone of an efficient and fair health system. As the 2014 Primary Health Care (PHC) Research Conference will be held on 23–25 July in Canberra, this issue includes articles with a focus on general practice, illustrating the investments this area needs and its important contributions to community health.

Australia has universal health coverage and health accounts for 8.9% of its gross domestic product — much less than other comparable countries (http://www.oecdbetterlifeindex.org/countries/australia) — which should promote equitable access based on need. However, 8% of patients already delay seeing a general practitioner because of cost (http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4839.0main+features32010-11) and studies have confirmed that preventive checks, such as for blood pressure, will be further reduced if a copayment is required, resulting in increased subsequent costs for treating complications and chronic conditions (MJA 2014; 200: 558-559).

Chronic conditions are increasingly prevalent, due to an ageing population and unabated epidemics of risk factors, especially obesity. Ironically, survivors of cancer are living long enough to be at risk of other chronic diseases, and Berry and colleagues (doi: 10.5694/mja13.10701) found that cancer survivors report more chronic conditions than do matched controls. Similarly, Pinto and Cooper (doi: 10.5694/mja14.00682) report that, while life expectancy for patients with HIV infection has improved dramatically with antiretroviral treatments, their rates of other chronic diseases are growing. A recent rise in new HIV infections in Australia is also cause for concern, and HIV strategies now aim to halve sexual transmission by 2015 and eliminate transmission by 2020.

Primary care is an important source of valuable data for advancing community health objectives. Sullivan and colleagues (doi: 10.5694/mja14.00106) used data collected by GPs as part of the Australian Sentinel Practices Research Network, which collects de-identified data on influenza-like illness and other conditions, to evaluate influenza vaccine effectiveness. They found that the overall adjusted vaccine effectiveness was 23% against all influenza types and, when stratified by age, 67% for older people. Letters from Mazza et al (doi: 10.5694/mja14.00732) and Harding et al (doi: 10.5694/mja14.00639) advocate data linkage to improve health outcomes. The former describe the benefits of linking general practice data to other datasets to map patient journeys through the health system and evaluate effective use of services, while the latter discuss linking data using unique health identifiers to enhance public health research.

The importance of translating quality research into practice is the focus of the supplement published online to coincide with the PHC Research Conference. Closing the gap between evidence and practice involves collaboration with all stakeholders, from researchers to end users — “Clinicians, managers, policymakers, consumers and bureaucrats are all involved”, write Jackson and colleagues in their supplement editorial (doi: 10.5694/mja14.00063).

Training an effective primary care workforce is a worthwhile long-term investment. Previous studies have shown that rural background and long-term clinical rural education terms influence medical graduates choosing to work in rural settings. The study by Wright and colleagues (doi: 10.5694/mja13.11329) demonstrated changes in attitude to working in rural locations after a compulsory 3-week placement for metropolitan medical students at the University of Melbourne. Students were surprised at the diminished access to health care, both geographically and by affordability, experienced by rural patients. Additionally, they did not anticipate the interprofessional teamwork they saw.

One potential team member in primary care is the nurse practitioner. However, Leidel (doi: 10.5694/mja14.00125) reports that this role seems to be in decline, and she advocates for greater involvement of nurse practitioners in primary care.

In an editorial, Kidd (doi: 10.5694/mja14.00787) says we have an obligation to share our solutions with other nations, while we can also learn from their primary care reforms. He notes the United Nations resolution “encouraging governments to move towards providing universal access to affordable and quality health care services”. We hope our own national leaders take heed and have the political will and commitment to ensure that Australians can continue to access affordable universal primary health care, and that the Australian health care system remains the envy of many other nations.

Nurse practitioners in Australia: strategic errors and missed opportunities

Urgent reform is required to make nurse practitioners responsive to Australian health needs and priorities

The Australian nurse practitioner (NP) movement was envisioned as an innovative solution to challenges in Australian health care. But more than a decade after the first NPs were authorised, growth has been slow and there is a real risk that they will fade into obscurity. Enrolment in some NP courses is plummeting, few new NP positions are being created, and nearly a third of NPs remain in their previous nursing positions despite completing a course.1 The nursing profession may blame this situation on opposition from doctors, but the NP movement has made strategic errors and missed many opportunities to create a flourishing workforce today. Without an uncompromising examination of these factors, the Australian NP role will continue on its troubled trajectory.

Nurse practitioners as clinical specialists

The Australian NP role originated as a career pathway for nurses who wished to formalise their advanced clinical skills.2 Essentially, a specialist nurse (clinical nurse consultant [CNC]) with expertise in an area such as colorectal cancer screening, remote health or sexual health would complete postgraduate studies leading to authorisation to practise as an NP.3 The NP title was borrowed from the advanced nursing practice role in the United States. Although Australian researchers often support their assertions with evidence from the US experience, the comparison is not apt, because NPs in the US originated as primary care providers.4 The NP role in Australia most closely resembles that of the American clinical nurse specialist.5

It is not clear whether, as a whole, health services have benefited from converting CNCs to NPs. In theory, given that they are able to prescribe some medications, order a limited number of diagnostic tests and perform some procedures, NPs provide an essential service that could not be achieved by a CNC or other health professional. However, more than 10 years after the inception of the NP movement, it is not known whether this is true in practice. The cost-effectiveness and patient outcomes of CNCs (and other specialist nurses) have not been compared directly with those of NPs.

Missed opportunities

During the early years of the Australian NP movement, primary care featured prominently on the agenda. Nursing leaders sought to formalise the high degree of skill and autonomy of rural and remote area nurses. In Western Australia, remote area nurses could apply to be NPs if they carried out similar functions to an NP rather than being required to undertake any formal educational preparation.6 However, beyond this early recognition, there was no substantive attempt to develop or evaluate rural and remote NPs, or to build a generalist university curriculum that would prepare graduates for remote practice. Interestingly, an American consultant who visited WA in 2004 foresaw poor sustainability among NP specialists and challenged the WA movement to align itself strategically with primary care.5 However, the momentum moved away from primary care, and subsequent role development occurred primarily in acute subspecialties. A 2009 study showed that only 5% of Australian NPs worked in remote practice.1

The NP movement also failed to align itself with the priorities identified by health policymakers. For example, the early NP curriculum was developed from interviews with NPs7 rather than from existing concepts such as the National Health Priority Areas8 or the key initiatives from Australia’s primary health care strategy.9 Using the National Health Priority Areas as a basis for curriculum and practice could have kept the NP role responsive and sustainable. Similarly, the Practice Nurse Incentive Program provided support for an expanded role for nurses in general practice, which could have been an opportunity for NPs to move into primary care — especially since it provided loading for rural and remote areas.10 If the NP movement had been more proactive and aligned with health priorities, an NP incentive program for general practice could have been proposed instead. It is not clear why these opportunities were missed. Perhaps the NP movement devoted its efforts to creating a place for itself at the top of the nursing hierarchy instead of reforming health service delivery in a broader sense.

NPs did not present themselves as solutions to the maldistribution of health professionals that Australia has always faced. Health Workforce Australia (HWA) was created in 2012 to plan solutions to workforce shortages in the health sector.11 It provided funding for nurse, midwife and doctor training, but did not fund NP education or clinical placements. In fact, HWA did not propose educating more NPs in its Health workforce 2025 report and did not include them on its clinical advisory panel.11 Moreover, a major HWA initiative to improve emergency department productivity and decrease waiting times was directed at emergency department nurses not NPs.12 This failure to influence national policy development and health reform threatens the sustainability of NP education and practice. It could make the role irrelevant. A major report declared the NP role to be a failed solution to the ongoing shortage of doctors in remote areas and proposed introducing physician assistants instead.13 Perhaps the lack of a flexible NP workforce explains the emergence of new roles such as physician assistants, extended-care paramedics12 and pharmacist prescribers.14

New roles require robust evaluation

Ongoing evaluation of the Australian NP role has not been robust enough to justify its continued progression. Much of the research uses the NPs themselves as the data source.15 Not surprisingly, these studies identified NP needs (not client or health service needs), such as a desire for more autonomy or a need for access to Medicare reimbursement. Evaluation of NP practice has focused on factors such as patient16 or colleague17 satisfaction rather than on key indicators such as cost savings, increased productivity or improved efficiency. Research reporting patient outcome data has not shed light on whether NP outcomes are superior to those for CNCs following standing orders. Even clinical ability has not been investigated rigorously — an NP research toolkit suggested that researchers should ask patients if “the NP seemed informed and up-to-date”.18

If the role is to be sustainable, NPs should perform activities that are not incorporated in other health professionals’ scope of practice (or that can be done with the most efficiency by NPs). Work-sampling research has shown that NPs spend most of their time on meetings and administration, and far less time on history-taking and physical assessment.19 This indicates that Australian NPs are not primarily clinical service providers (as they are in countries with a thriving NP workforce, such as the US). It also indicates that there may not be a substantive difference between a CNC and an NP. Unless more rigorous evidence emerges that the NP role adds value to a health service, employers will find it difficult to justify using clinical specialists to spend most of their time on non-clinical activities.

The way forward

The Australian NP movement is at a crossroads. If NPs are to become sustainable and integral parts of the health system, innovation and reform are urgently required. The NP’s place in the nursing hierarchy should be re-examined. Perhaps the CNC role could be developed in a way that formalises specialist nursing practice rather than converting it to an NP role. In order to produce NPs with skills that can adapt to changing health needs, they should be educated according to a generalist framework based on national priorities. If NPs want to advance, they should demand a seat at the policy table and provide a voice for their patients. Further, NP research should move beyond self-examination and patient-satisfaction surveys. Evidence of cost-effectiveness, quality of care, efficiency and productivity will be required to sustain the role. Direct comparisons between CNCs and NPs must be made if employers are to support new NP positions. Above all, if the NP movement is to progress, NPs must demonstrate that they provide flexible solutions to the highest priority health concerns in Australia.

Linking data to improve health outcomes

To the Editor: The editorial by Olver1 is a reminder of the usefulness of linking health datasets for research and evaluation. While data linkage is not a foreign concept to many health services researchers, such work with regard to Australian primary care is very limited. The recent review of Medicare Locals noted that the few linkages created “only occur in pockets and are often constrained by administrative, collaborative and/or legislative factors”.2 The public interest is not served by these barriers.

The unavailability of and lack of access to general practice data have hindered our ability to build a comprehensive picture of the interface between general practice and other health care services.3 The benefits of linking anonymised, individual-level general practice data with other routinely collected health data are enormous; it enables us to map the entire patient journey both retrospectively and prospectively, gives us an insight into patients’ use of health services, and provides us with the opportunity to assess whether the organisation of care for patients is effective and whether health services can be accessed by patients at the “right time”. Such capabilities are very relevant for addressing issues such as the increasing demand for emergency department services and access to after-hours medical care.

Further attention to and investment in securing general practice data is urgently required. Until this is achieved, we will be unable to fully realise the benefits of data linkage for informing health policy and practice in primary care.

Implementation research – its importance and application in primary care

Moving evidence from theoretical to practical levels requires a collaborative effort

The gap between what we know can optimise health care outcomes and what is everyday practice, remains a major challenge for health systems.1 Implementation research seeks to close this gap by using scientific methodologies to support the movement of research-based evidence into policy and practice.2,3 Sometimes used interchangeably with the terms translational research and implementation science, implementation research seeks to understand and maximise the uptake of quality research by potential users — in our case, the busy and complex clinical and health service environment. Interest in primary care-based implementation research is growing rapidly, as governments seek to maximise investment in research for its citizens.4

Last year, the Strategic review of health and medical research — better health through research (the McKeon Review) made 21 recommendations for improving the nation’s research quality and productivity. A focus on implementation research was central, with “strengthened partnerships between researchers, health professionals and the community”, facilitated “translation of research into evidence-based healthcare and policy” and measures to “enhance health services research” identified as important priorities.5 We are fortunate that the Australian Primary Health Care Research Institute (http://aphcri.anu.edu.au/about-us) has long promoted such strategies and encouraged our Centre of Research Excellence to explore this approach to industry–research partnership within all programs.

Research findings coming down the pipeline from clinical trials are not always fit for purpose across a complex health system. Clinical trials for efficacy emphasise internal validity, controlling for all factors except the one being tested. This means the application of these findings is frequently problematic in the real world, where external factors play a crucial role. Implementation research, with its requirement to work with end users, emphasises external validity. This highlights the need to develop hybrid designs, balancing both internal and external validity, to achieve maximum uptake.

Implementation research methodology is developing rapidly, using multiple theories and approaches to identify, operationalise and understand implementation processes, mechanisms and causal influences. There is an emphasis on mixed methods, including realistic review, hybrid efficacy–effectiveness trials, and implementation salvage to understand when and why interventions fail. In health, it often focuses on the complex barriers and enablers to the systematic uptake of evidence into routine practice. This includes an understanding of the interplay between science and health professional, and organisational behaviour, population-under-care and local delivery environment, in the adoption of new knowledge.

This supplement reports early results of a specific approach to implementation research, based on normalisation process theory6 and the co-creation paradigm.7 This approach closes the evidence–practice gap by involving end users in every step of the research process: shaping the research questions, methodological approach, implementation challenges and identifying the most important outcomes. Clinicians, managers, policymakers, consumers and bureaucrats are all involved. This process requires extensive consultation, flexibility and front-end review and adaptation.

Articles in this supplement describe the positive impact on practitioner participation, policy intelligence and end-product use. Janamian, Jackson and Dunbar report the perspectives of influential national organisations partnering with researchers to use this approach (doi: 10.5694/mja14.00273). Abou Elnour and colleagues describe surveyors’ perceptions of the impact of accreditation on patient safety in general practice (doi: 10.5694/mja14.00198). Crossland and colleagues report on the development of a quality and safety practice e-tool, co-created with a range of partners, which they then pilot tested in several general practices in Queensland (doi: 10.5694/mja14.00262). Hernan and co-workers report on patient perceptions of safety and quality in rural general practice (doi: 10.5694/mja14.00193). In a “for debate” article, Wilkinson and colleagues call for increased clarity and general practice involvement in caring for women during and after a pregnancy complicated by gestational diabetes mellitus (doi: 10.5694/mja14.00251).

Health care reform is a feature in many countries, driven by global trends such as diminishing health returns for investment in health care, and demographic trends in populations that age and become more diverse in health need. Primary health care is the generally accepted road towards a robust, cost-effective health care system,8 which makes its inclusion in research partnerships a pivotal component. An essential objective of health care reform is to respond to the needs of populations, and this requires the system to understand and adapt to local circumstances. Effective implementation research must therefore be directed bottom-up from the community, through effective and consultative partnerships at every stage.9 Although this requires a refocus on the way we conduct health services research, such relationships are essential to ensure limited investigative and implementation resources are deployed to maximum community benefit.

Co-creating value in research: stakeholders’ perspectives

A Centre for Research Excellence reflects on collaborating with policymakers and front-line staff to bring evidence into practice

Last year’s Strategic review of health and medical research – better health through research (the McKeon Review) highlighted strengthened partnerships between researchers, health care professionals, government and community as central to a productive research sector.1 Our Centre for Research Excellence (CRE) has, from inception, adopted such an approach to facilitate translation of our research into evidence-based health care and policy.2 Implementation research works best when the research partners who make policy or deliver care have been involved at all stages of the research process — from the research question through to the analysis and implementation strategy.3,4 In using these approaches, our CRE has partnered and worked closely with a variety of influential primary care organisations (Box). Collectively, they represent members delivering more than 100 million patient consultations per year or organisations responsible for setting the quality and safety benchmark for Australian primary care.

From 2011, our CRE has had regular “linkage and exchange”5,6 activity with all partner organisations. This includes a variety of different communication methods — regular full-day research planning meetings, providing opportunities to receive updates and provide feedback, and informal input and advice around the CRE’s research program. Our partner organisations also sit on our Research Stream Committees and National Advisory Committee, providing them with more formal opportunities to engage with the research team. As our partners reflect the heterogeneity of the end users of our research, this allows them to influence new approaches, generate fresh ideas and provide advice on existing frameworks.

In this article, we record insights from these nine organisations about their experience in working with our Centre. Our information was obtained from senior organisational representatives in open-ended telephone interviews, either individually or in small groups. Three key areas were explored: general perceptions about the partnership to date, the benefits and challenges of coproduction and implementation, and thoughts on future initiatives of this kind. A journalist independently recorded the representatives’ responses, and the transcriptions of these are included in this reflection piece.

Benefits of the collaboration

Most key informants perceived the collaboration to be value-adding and enriching.

Partnering with the CRE has helped us identify new opportunities and has added credibility to the quality frameworks we have in place. The ideas the Centre has brought to the table have developed our thinking. We have been able to consider and incorporate their quality improvement activities into our existing processes to add value to what we do. The open communication channels have been excellent throughout the process. (RACGP)

Most partners reported the collaborative relationship as respectful and open.

There has been good communication from the research team back to us, and the research has been professionally led and well managed. (AGPAL)

The partners were pleased to see the CRE bringing together key stakeholders from a range of disciplines to work together towards a common goal:

The thing that I’ve particularly valued has been the broader meetings that we’ve held at various times. To be able to hear people from a huge range of disciplines and perspectives actually sharing with one another and working towards a shared goal. (CIA)

The research team perceived working closely with the organisational end users to have been highly beneficial to the CRE research program. It allowed fine-tuning of research to produce outcomes implementable by partner organisations, particularly coproduction of research questions designed to generate the product identified by partners.

Partners identified issues of relationship, pragmatism and relevance as important.

The relationship is the important thing, and its what’s been missing in other forms of what you might call applied research where a researcher goes away, undertakes the research and then perhaps publishes a paper, which then misses the bit as to “how do we get it implemented” … This change from the top-down focus of previous programs could result in fewer failures and more successes and, generally speaking, better value for money. (IFA)

We wanted research that is practical, with commonsense outcomes that people can understand. That is what we have achieved … and we recognise there will be useful outcomes. (AGPAL)

Partnership has permitted progressive road testing of processes, findings and recommendations, which has been invaluable. Partners appreciate that the CRE conducts research that is practical, relevant, and will produce outcomes that can be operationalised by partner end users almost immediately.

A lot of the research that’s normally done on the policy level is at a macro level — good ideas but vary rarely implemented in practice. People on the frontline are actually having significant input to the process and being able to inform the way that the practice improvement tool is developed. I think that’s really important. (AAPM)

The partnership with the CRE has enabled us to actually have discussions so that we can make clear what are the needs of the organisations to enable them to make change, and the CRE gets involved in taking that on board in their research to indicate what might work best to help with patient safety improvement. We’ve also been working with the CRE in helping identify the best practices throughout Australia so we can work more closely and find out what makes them the best practices. By and large, it’s been a process that has enabled us to have communication with the researching body who have worked with us in identifying the needs, the topics and of course now are involved in an interaction in how it might be implemented within our improvement framework. (IFA)

Further benefits relate to the CRE assisting stakeholders to improve quality and build accreditation options. Involvement in our research program has offered an opportunity to gain quality improvement and continuing professional development points through the RACGP, and, more recently, professional development points for practice managers through the AAPM.

It assists in their accreditation. They’ve got a system in place that will help them with continuous improvement and that does flow onto patient care and safety. It has empowered the practices to make changes towards quality improvement. (AAPM)

The CRE has found access to the partner organisations’ membership and networks for recruitment to its research program invaluable. Through these, we have successfully engaged hundreds of practices across Australia to participate in our research program. This helps develop research capacity in primary health care organisations and practices and is consistent with both APHCRI’s mandate and the McKeon Review, which states that “research capacity among health professionals is critical for conducting research, promoting research translation and improving the health system”.1 Most partner organisations raised these benefits, and noted that the CRE has promoted involvement of the entire practice and primary care staff, not only general practitioners.

Previously, I think, people have thought it’s really the physician’s role and nothing to do with the office staff at all but this [CRE] has made it really clear that it’s the responsibility of the whole team and shows how they can all contribute to the end result which, of course, is patient safety … people who have participated in the research have found it beneficial to their practices and to them personally. (AAPM)

It is well documented that only a fraction of research is translated to policy and practice.7 Our Centre addresses this gap by involving influential partners in both the creation and dissemination of evidence-based research into policy and practice.8 We have regularly engaged with policymakers to ensure that our research production aligns with their needs for easy uptake into policy and service delivery. It is pleasing that this style is welcomed by government, but is an area that requires more work.

This relationship with the CRE reflects the broader move in government to have evidence at the centre of policy making … whilst we articulate that as an ideal, we are still in the process of determining how we do that. (DoH)

Challenges of the collaboration

Working across the research–policy interface often poses challenges related to differing cultures, priorities, preferred style of communication, and time frames.

The research method takes years to produce its outputs and the questions that policymakers seek answers on don’t always coincide with the time scales in the research … the challenge that we face is to how to articulate the policy need and the importance of this research in the absence of outputs. (APHCRI)

The policy-making process is not necessarily a linear process that happens in discrete time frames. The capacity for the CRE to work with us in that environment is going to be different at times for the CRE where they want to start a project and progress through in a neat timeframe. (DoH)

It was acknowledged that it takes commitment and time to build relationships and address cultural differences.

It is early stages and is still a maturing relationship. I think from both sides, there are different cultures and different contexts in which we work. It takes time to actually build that relationship up and understand those different contexts, and for two different cultures to come together to do something new. (DoH)

When asked regarding enhanced collaboration, several partners felt that their involvement was limited and would have preferred to be engaged more intensively:

To continue involvement we want to be kept involved at a higher level. There is the quarterly magazine, APNA annual conference … it is a great opportunity for the CRE and really good for APNA to be able to let people know what we are involved in. (APNA)

It has worked well, but sometimes, I feel disconnected from it. That is probably largely from the Commission end rather than the CRE end. If we were starting again I would push harder to be more involved. (ACSQHC)

The future

APHCRI CREs have unique assets in staff and skills linked to extensive national and international networks for primary care capacity building.

It would be useful to extend some of this preliminary work. Good primary health care has a positive impact on the overall health system and research is essential to achieving those improvements. (RACGP)

Most partners felt that it has taken significant time and energy to build the relationships required to effectively conduct research in partnership, but there is much work yet to be done.

We’ve brought them to a level where they’re working well together and delivering … so how can we maintain these relationships? It often is reliant on the personal relationships that have been built up. (CIA)

I think it has been good in terms of starting that relationship, working together and a willingness to cooperate but I don’t think we’ve got the fullness of maturity yet that we would like. (DoH)

All informants recognised the importance of the CRE in building “grassroots” capacity to deliver practical solutions for improving patient safety, clinical outcomes and overall quality of care, and indicated an interest in continuing their involvement in research development of this nature. The interlocking of end user and researcher across the entire Centre research journey has taken time, patience and flexibility on both sides. Yet the benefits in terms of research translation and utility have already been significant, and are documented in each paper in this Supplement. Research end users, are critical and willing partners in closing the primary care evidence–practice–policy loop, for the benefit of all Australian communities.

Centre for Research Excellence in Primary Health Care Microsystems Research partner organisations

Australian Association of Practice Managers (AAPM)

Australian Commission on Safety and Quality in Health Care (ACSQHC)

Australian General Practice Accreditation Limited (AGPAL)

Australian Government Department of Health (DoH)

Australian Primary Health Care Nurses Association (APNA)

Australian Primary Health Care Research Institute (APHCRI)

Chronic Illness Alliance (CIA)

Improvement Foundation (Australia) (IFA)

Royal Australian College of General Practitioners (RACGP)

Patients’ and carers’ perceptions of safety in rural general practice

Engaging with patients to gain an in-depth understanding of their preferences, beliefs, values and contexts facilitates delivery of safe, high-quality care.1 Patient-centred care2 and being responsive to patient needs and desires is an international concept that is well recognised in the patient safety and health care quality literature.1

The importance of obtaining patients’ views about the health care they receive has been endorsed through the promotion of the Royal Australian College of General Practitioners standards.3 For accreditation to the standards, practices must regularly use an approved patient feedback tool, and must have a process for receiving and managing patient complaints.3 While such feedback enables comparisons at a health system level, it does not elucidate how patients think about safety and their involvement in health care. Qualitative methods can be used to uncover the complex, multifaceted issues concerning patients’ views of safety and quality in health care.4

In Australia, there has been ample research on patient preferences regarding quality of care in general practice5–10 and what constitutes the major incidences and causes of harm in this setting.11 Additionally, there has been some work on understanding what Australian patients know about problems and failures in health care,12 and adverse event and incident disclosure.13 A recent review found that only a small number of qualitative studies have been conducted with rural populations concerning quality of care, but none has focused on patient perceptions of safety in general practice.14 It is important to understand rural patients’ perspectives of safety, as they may have specific needs or different perspectives from urban populations.

With this in mind, we aimed to explore patients’ and carers’ experiences of rural general practice and to identify their perceptions of safety in this health care setting. We chose to conduct focus group interviews to gain a rich understanding of people’s attitudes, beliefs and views about their lived health care experiences.15

Methods

We targeted rural and regional patients and carers from south-west Victoria who were frequent users of general practice, such as those with a chronic condition, on repeat medication, older people and mothers with children. These patients were believed to have more experience with general practice, and therefore to have greater insight into specific safety issues.

Participants were recruited through local community health or allied health organisations between August and November 2012. Recruitment sources comprised education and support group meetings for type 2 diabetes self-management, cardiac rehabilitation, group exercise and a mothers’ group. Individuals were provided with study material, and if they were interested, they self-selected into the study.

The Flinders University Social and Behavioural Research Ethics Committee granted ethics approval (project no. 5667). Participants provided informed written consent and received a $50 shopping voucher for their time and travel expenses.

Focus group protocol

We conducted a series of focus group interviews between September and December 2012. They were recorded and transcribed verbatim. We administered a questionnaire to obtain basic demographic information before the start of each focus group.

A semi-structured focus group interview protocol was developed to gain a broad understanding of patients’ and carers’ experiences of care (Box 1). This exploratory study required a flexible approach and the use of general concepts that could be further refined and revised during data collection. Questions were adapted and follow-up questions were asked to probe particular safety points of interest from previous focus groups, and to confirm or contest these issues.

Focus group data were analysed using a thematic and iterative approach to identify the safety issues evident in participants’ narratives. Narrative analysis was used to explore and interpret the lived experience of individuals.16

Transcripts were reviewed by two authors (A L H and C W) and analysed using the constant comparative method to inductively generate a coding structure that outlined themes and subthemes. After the researchers reached consensus on the coding structure, the codes were applied to the entire set of interviews. NVivo 10 (QSR International) was used to support the analysis.

Results

During recruitment, 114 individuals were approached, with 32 providing consent. Twenty-six participants took part in one of four focus group interviews in the Victorian towns of Balmoral, Hamilton, Merino and Portland. Each group had three to 10 participants. Reasons for not participating in the focus groups included being too ill to attend, not able to attend at the specified time and date, loss of interest, and failing to attend. Box 2 shows participants’ demographic characteristics.

Participants who had experienced some level of harm were able to comment more extensively on safety aspects of care; however, themes related to safety were identified from the analysis of all participant narratives. Box 3 provides illustrative quotes associated with the key themes.

Risk awareness

Although not explicitly recruited with these criteria in mind, there were two types of participants — those who had experienced harm and those who had not. Harm was experienced in hospital care and general practice care, with the former being more common in the participants’ stories. The severity and seriousness of the circumstances that led to hospitalisation and the errors that occurred during the hospital journey created a heightened sense of awareness for safety in the hospital. Compared with hospital care, perception of risk in the general practice setting was perceived differently by some participants. Continuity of care and trust in the doctor–patient relationship allayed perception of risk.

Trust

Participants spoke of the characteristics of GPs that contributed to a sense of trust, which included confidence in their clinical competence and having personal knowledge of the patient.

When participants had experienced harm in general practice, their trust was compromised to varying degrees. Some patients took action to rebuild this trust, while others ended their relationship with that GP and sought care elsewhere.

Participants who had not experienced harm relied heavily on their trust in provider. Some were forthcoming about their lack of knowledge or understanding of safety, and their limited ability to accurately identify when risks could occur. Experience and expertise of the GP were additional factors which promoted trust.

Vulnerability

Participants described feelings of vulnerability in their experiences of care. Many suffered from multiple chronic conditions and therefore considered themselves more at risk of harm, whether these were clinical or psychological harms. Reported clinical harms included misdiagnosis, delays in treatment, not adhering to standard care procedures, and medication errors. Psychological harms that some participants experienced included verbal abuse, name calling and other disrespectful or dehumanising behaviours or practices such as lack of eye contact, and dismissive, rude or aggressive interactions.

Even participants who had not experienced harm emphasised their need to be treated with respect as an individual by the GP, demonstrating a collective sense of vulnerability faced by the general population of patients.

The power dynamics between the patient and the doctor also contributed to patient vulnerability. When participants attempted to voice their real or perceived fears about their health conditions to their GP, power imbalances between patient and provider led to feelings of embarrassment and foolishness.

A forgiving view of mistakes

Some participants considered mistakes or errors in their care as “normal”. They expressed an understanding and sympathy towards the GP’s situation and considered mistakes as part of being human. Many viewed the GP as an ordinary person in their community, not “god-like” or omnipotent.

The familiarity and continuity of the doctor–patient relationship in general practice may have enhanced this forgiving view of mistakes, when compared with one-off and short encounters with health professionals in hospital settings. The sense of closeness experienced in a rural community may also account for the differential tolerance of hospital versus GP mistakes.

Desire for an explanation and apology

Participants lacked appreciation of the systemic nature of medical error, and as a result they placed responsibility for errors solely on the GP. In contrast with accountability for errors, participants described system barriers that prevented GPs or other health care professionals from apologising and acknowledging patient harm, including a medical culture fearful of litigation.

Nevertheless, they reported a need for an explanation of what went wrong and why, and they described apology as the most effective way for patients to recover and move on from an incident. Some participants described feelings of admiration for those clinicians who apologised to patients when errors occurred despite the perceived threats of litigation.

Appreciation of general practitioner interpersonal skills over competence

Some participants did not focus on the safety of their care, but rather the GP’s interpersonal skills. In these instances, participants appeared to value the interaction and relationship with their GP without seeming to question the GP’s clinical competence. A desire for a caring GP and other relational attributes were considered to be more important, and care was assumed to be safe.

Discussion

Our study aimed to identify patients’ perceptions of safety in general practice and explore the factors contributing to the development of these perceptions. Many of the participants had an assumed sense of safety in the rural general practice setting. Only those who had experienced harms were able to comment extensively on safety, and much of this concerned experience with or awareness of hospital safety issues. Those who had not experienced harm did not conceptualise it, and furthermore, when these participants were in a trusting relationship with their GP, they assumed that the care provided was safe.

These findings directly contest previous research, which found that patients who have experienced harms in hospital settings could accurately identify and report on safety incidents,17,18and make recommendations on improvements to safety.12 Even the general public have an awareness and understanding of safety in health care due to increased amount of research, media attention, and political interest in recent years.19 However, much of this research has occurred in hospital settings and may not be applicable to the general practice setting, where issues of trust, vulnerability and preferences for interpersonal skills are prominent over safety.

Individual contribution at the beginning and throughout the focus group discussions was emphasised through the use of a skilled facilitator to minimise agreement bias. Interpretation bias was acknowledged and avoided through independent data review and analysis. Although there were only 26 participants, the issues raised reflected a diversity of views and experiences.

An assumed sense of safety is a concern, given that general practice is the first point of contact for most people seeking medical care, and its high volume of repeat interactions and frequency of adverse events.20In our study, risk perception in general practice was mediated by a variety of different factors. Trust was the most prominent factor, and it may mask the patient’s ability to identify possible threats to safety and hence reduce risk awareness. Trust in the patient–provider relationship has been researched,21 and has been used as a model to improve patient involvement in safety, with mixed results.22,23 The nature of general practice makes it amenable to the creation of trusting relationships between patients and doctors. However, patients reverting to a default position of trust when they believe they do not have sufficient knowledge or skills, or are not in a position to adequately comment on safety,24 is problematic because patient awareness of and involvement in safety has been shown to improve clinical effectiveness, health outcomes and satisfaction with care.25

This study also revealed unique safety-related themes. Feelings of vulnerability have been reported by patients with chronic diseases.26 Interaction and communication between the patient and the GP is important to reduce feelings of vulnerability and ensure that patients feel comfortable and confident with their GP. Effective communication during the consultation is the key to facilitating safe and high-quality care; however, there is no “one size fits all” approach, as patients’ preferences and desires for a style of interaction vary widely. Being flexible and adaptable to patients’ different communication needs has been recommended as a solution to the limitations of general communication guidelines.27 Further, communication with patients extends to the disclosure of errors when they occur. Patients in our study and in others28 expect an honest and timely apology where appropriate and explanation of what went wrong. While there is a code of conduct in Australia referring to open disclosure of medical errors, there are still gaps in compliance and patient satisfaction with this process.13

We found that only patients who had experienced harm were able to comment on safety issues, and safety was largely seen as a problem in secondary care. New insights into the factors that influence the development of safety perspectives have demonstrated the value of incorporating the patient voice into safety research. These findings contest current research on patient involvement in safety, and warrants further exploration.

1 Focus group interview questions and prompts

The primary questions posed in the focus groups were:

1. Can you describe what is involved in a normal visit to your general practitioner?

Prompts: Ringing to make an appointment, arriving at the
clinic, waiting time

2. Can you describe your relationship with your GP?

Follow-up question: What makes a good relationship?

Prompts: Communication, trust, information provision

3. What other staff do you come across at the GP clinic?

Prompts:Reception staff, practice nurse, practice manager

4. Is there anything about the clinic that influences you wanting to go there?

Prompts:Car parking, disability access, cleanliness

5. What is most important to you about the care you receive at your GP clinic?

Prompts:Patient-centred care, patient involvement in care

6. If you could improve something about the care you receive, what would it be?

Prompts:What do you do when things go wrong?

Prompts:Awareness of safety issues, risk perception

2 Demographic characteristics of the 26 focus group participants

Characteristic

Women, no. (%)

14 (54%)

Pension card holder, no. (%)

18 (69%)

Health care card holder, no. (%)

15 (58%)

Married, no. (%)

16 (62%)

Secondary education (years 7–10), no. (%)

10 (38%)

Retired, no. (%)

15 (58%)

Repeat prescription, no. (%)

18 (69%)

Common health conditions, no. (%)

High blood pressure

11 (42%)

High cholesterol

10 (38%)

Arthritis

10 (38%)

Mean age in years (SE); range

59 (3.8);
range, 27–83

Mean number of health conditions (SE); range

3 (0.6);
range, 0–14

Mean number of visits to general practitioner in previous year (SE)

12 (2.3)

SE = standard error.

3 Participant quotes associated with safety themes

Risk awareness

If I know I’m being looked after I feel safe. Like if I know, all right, they may not have all the answers but people are onto it … people are working together with me and then I feel safe. Whether it’s like my current doctor who doesn’t know anything much about my condition anyway, but he’s working together with my cardiologist and they’re working it out together and so I feel quite, far safer than I have in a very long time so. But not so with the hospital. That’s a different thing. (37-year-old woman with a congenital chronic condition)

[Hospital acquired infections] are the things you see in the major hospitals that cause havoc. Where … what you end up with is worse than what you went in with. (83-year-old man with multiple chronic conditions)

Trust

The thing is … when you don’t have confidence in a doctor either a) because of something they’ve done or b) because you don’t know them, it makes life even that more difficult. (69-year-old man with multiple chronic conditions and a carer)

Conversation between two participants:

P1: You don’t know I don’t reckon … I’m just like “whatever” you know like I didn’t want to be there so they kept coming and saying “oh we’ll try this”, and I’m like “yep whatever go for it”, you know … (27-year-old mother)

P2: You trust, yeah. (28-year-old mother)

P1: … you just “OK”, you’re just in there, you know, emotional to say the least … you have no idea what’s about to happen … Well they’re doctors and they’re nurses and they’ve probably done it 100 times before, they all know. You just go with it, like that’s me and I’m one of those personalities to just say “yep, yep OK”. I just trust that they know what they’re doing.

Vulnerability

… [we] told her that his bowel habits had got worse, they changed, he wasn’t feeling that well and everything. And he said I wouldn’t mind a colonoscopy and she’s saying “you don’t need it, I’ll give you something else for your haemorrhoids”. After she finished we were getting ready to leave and he said “I’d really like a colonoscopy” and I can still see her sitting there, she was kinda half turned her back to us with the computer and she looked over like that [over shoulder] and she said “I cannot send you for a colonoscopy like that for haemorrhoids” … he felt really stupid for asking then … We did feel rather foolish the way she spoke with us … (64-year-old woman carer)

Conversation between two participants:

P1: You’re vulnerable. You’re vulnerable to them … (37-year-old woman with a congenital chronic condition)

P2: Yeah, yeah. (73-year-old man with multiple chronic conditions)

P1: And you’d prefer if they don’t abuse that …

P2: We’re pretty frail creatures, aren’t we, when it comes to sickness?

A forgiving view of mistakes

I felt that, ah, more should have been done when I went to doctor for a respiratory problem … Not a sign of sounding me or doing anything like that, but he was busy and as I was told he was having a bad day, and the phone had gone out and a few things like that. Well OK, he’s only human. (83-year-old man with multiple chronic conditions)

Desire for explanation and apology

I’d prefer someone to say to me “look I’ve made a booboo”, “yes you’re right”, “OK, we’ll make sure that doesn’t happen again”. All over red rover. (73-year-old man with multiple chronic conditions)

Conversation between two participants:

P1: Like, I feel like you need an explanation and why everything went chaotic. I think they should explain this is what happened. They can’t tell you at the time because it’s all happening. (28-year-old mother)

P2: No, nobody was telling me anything. (35-year-old mother)

P1: But afterwards I think you definitely need a, your doctor should debrief you and say this is what is happening; this is why we did this and that.

Appreciation of general practitioner interpersonal skills over competence

… so I went to there and, um, this fella was a lovely fellow but he had no idea about five of the illnesses that I had suffered from. He had no idea about what medications I ought to take. He still doesn’t figured out what the blood tests I get for the leukaemia, and um, so you know, that’s where, but he is a lovely fellow, and I love going to him because we have a good chat … (70-year-old man with multiple chronic conditions)

P1 = participant 1. P2 = participant 2.