Developing an Intervention to Support GPs when Communicating with Patients with Emotional Concerns

Abstract

One in four people experience mental health problems each year worldwide. General Practitioners (GPs) are the most commonly used provider of mental healthcare in the UK, with up to forty percent of GP consultations involving a psychosocial component. The identification and management of emotional concerns is achieved primarily though GP-patient communication. GPs’ interpersonal skills are highly valued by patients and associated with improved treatment outcomes. However, current communication guidelines for GPs do not clearly define the skills required. Furthermore, it is not well understood how these skills are used in the context of a busy general practice. Therefore, the aim of this thesis was to develop a conceptual model of an intervention to support GPs when communicating with patients with emotional concerns. Intervention development followed the Medical Research Council’s framework for the development and evaluation of complex interventions, supplemented by Bleijenberg’s complex intervention development guidance. The development of the intervention was informed by five empirical studies. Study one was a systematic review and qualitative synthesis of thirty articles exploring barriers and facilitators to GP-patient communication in UK primary care. Four key barriers were identified: 1) patients find emotional concerns difficult to disclose, 2) both GPs and patients experience a tension between understanding emotional concerns as a medical or social phenomenon, 3) patients have varying preferences for involvement in decisions in their care, and 4) GPs find it difficult to provide adequate care in short consultations. Three facilitators to GP-patient communication were: the therapeutic GP-patient relationship; exploring, explaining, and negotiating a shared understanding; and involving and informing patients throughout the consultation. Studies two and three were focus group studies with eighteen patients (study two) and seven GPs (study three), analysed using reflexive thematic analysis. These studies aimed to explore GPs’ and patients’ experiences of providing/ seeking help for emotional concerns, and their priorities for improving practice. Focus groups with patients found that a therapeutic GP-patient relationship was considered to be intrinsically healing; that patients wanted their GP to help them to understand the root of their concerns; and that patients preferred a collaborative partnership with their GP but their preferences for control were dynamic. Focus groups with GPs also highlighted the healing nature of the GP-patient relationship. GPs also discussed how patients’ emotional concerns are understood as the result of a negotiation between patient and GP belief models, and that GPs felt personally responsible for supporting patients through their care journey. However, GPs face barriers due to lack of time as well as pressure from guidelines which encourages them to prioritise high-risk patients. Studies four and five were two conversation analytic studies of video recorded GP-patient consultations from the One in a Million dataset. Study four explored how GPs use so-prefaced declarative questions – known as formulations – to develop a shared understanding of patients’ emotional concerns. Formulations were useful for bridging the gap between assessment of often sensitive emotional experiences and managing the medical agenda, and appeared to enhance the doctor-patient relationship while facilitating the pursuit of necessary institutional tasks in highly time constrained consultations. Study five explored how GPs ask patients questions about sensitive topics such as suicidal ideation and drug use. Study five found that GPs used two key techniques – highlighting the sensitivity of the question and creating context – to reduce the threat that asking these important questions posed to the doctor-patient relationship. These studies were then used to inform the development of a complex intervention, supported by Sermeus’ modelling scenario. The intervention model consisted of three interrelated intervention components – ‘the GP-patient relationship’, exploring and understanding patients’ concerns’ and ‘working on the problem together’. The conceptual model represents how these components work together, the underlying forces involved, specific actions to implement the intervention, and contextual factors. Incorporating GP and patients’ views and preferences into a conceptual model of care improves the likely acceptability and feasibility of this intervention. This intervention model could be utilised in GP training and guidelines as a valuable tool to enable GPS to better support patients who are experiencing distressing emotional concerns in primary care.