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General practice / Family practice
Original research
Patient, carer and healthcare professional experiences of complex care quality in multidisciplinary primary healthcare centres: qualitative study with face-to-face, in-depth interviews and focus groups in five French multidisciplinary primary healthcare centres
  1. Jérémy Derriennic1,2,
  2. Marie Barais1,2,
  3. Delphine Le Goff1,2,
  4. Guillaume Fernandez3,
  5. Françoise Le Borne3,
  6. Jean-Yves Le Reste1,2
  1. 1Department of General Practice, University of Western Brittany, Brest, Bretagne, France
  2. 2EA 7479 SPURBO, Université de Bretagne Occidentale, Brest, Bretagne, France
  3. 3LABERS EA 3149, Université de Bretagne Occidentale, Brest, Bretagne, France
  1. Correspondence to Dr Jérémy Derriennic; jeremy_derriennic{at}hotmail.com

Abstract

Objectives To explore care experiences in multidisciplinary primary healthcare centres from the patients, carers and healthcare professionals perspectives.

Design This qualitative study used face-to-face, in-depth interviews and focus groups. Patients with multimorbidity monitored by a General Practitioner (GP) and another professional from the health centre were recruited through purposive sampling and included with their carer. They were interviewed together while professionals were interviewed separately. Verbatims were coded with subsequent blind analysis, using an inductive approach, to find aspects and features. The constant comparative method highlighted data consistencies and variations.

Participants Twenty-six patients, 23 family carers and 57 healthcare professionals.

Setting Five multidisciplinary primary healthcare centres, in France, between March 2017 and December 2018.

Results This unique study grouped perspectives into nine core quality of primary care aspects: having accessible, available, and varied care; feeling welcome and enjoying comfortable, well-equipped, and clean premises; having quality medicotechnical care (medical knowledge and technical skills); having a reliable GP; receiving appropriate care from healthcare professionals other than the GP; maintaining an efficient relationship with healthcare professionals; benefiting from organised and coordinated care; being an informed, supported and involved patient; having an informed, supported and involved carer. New areas of interest include the multidisciplinary nature of the centres, appreciation of other professionals within the centre, medicotechnical dimensions of care and the carer’s role in maintaining patient autonomy.

Conclusions This is the first study to interview patients and carers alongside healthcare professionals. This enhanced knowledge improves understanding of these aspects and can guide implementation of evaluation tools that truly reflect patient and carer needs and enable an efficient experience in terms of quality. To address deficiencies in existing questionnaires, the new perspectives found will be added to former aspects to create a comprehensive quality of primary care evaluation tool.

Trial registration number NCT02934711, Results.

  • primary care
  • qualitative research
  • quality in health care

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this article and in its online supplementary material.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2021-050165

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    Strengths and limitations of this study

    • This is the first qualitative study to explore care experiences in multidisciplinary primary healthcare centres from the patients, carers and healthcare professionals perspectives.

    • The appreciation of other professionals, besides general practitioners, was explored for the first time.

    • Four members of the research team conducted blind analysis of the codes using an inductive approach in a content analysis perspective.

    • The constant comparative method was used to highlight data consistencies and variations.

    • This study provided a new perspective by interviewing carers alongside the patient and healthcare professional which has not been done before.

    Introduction

    The increased prevalence of multimorbidity is associated with medical advances, an ageing population and lifestyle risk factors.1 2 Providing effective healthcare for patients with multimorbidity is a global challenge and an increasing priority.3 Carers, often a family member, play a central role in patient care alongside healthcare professionals (HCPs) and patients. They are involved in decision-making, monitoring treatment adherence and coordinating care4 but are often overlooked. Nevertheless, healthcare systems are slowly shifting away from disease-focused models to chronic disease management models that are centred around patients and carers.5 General practitioners (GP) manage these complex cases and their associated social and psychological problems using a holistic approach.5 Multidisciplinary primary healthcare centres (MPHCCs) could therefore provide the best care for these patients with multimorbidity.6–8

    In France, GPs are considered to be the cornerstone of the healthcare system. Patients are free to choose their GP and GPs are able to organise their practices as they see fit. Different configurations exist including single professional practices with one or multiple GPs in one centre or multidisciplinary centres.9 For several years, the French Health Authority (HAS) has financed multidisciplinary centres10 and therefore monitors their productivity and economic value closely. However, the HAS recently concluded that quality of care and patient experience in these centres should also be assessed.10 Assessing patient care experience may be an important element in understanding the relationship between multimorbidity and the quality of care that healthcare systems deliver. Patient experience is defined as the sum of all interactions influencing patient perceptions across the continuum of care, and is increasingly recognised as one of the three pillars of healthcare quality alongside clinical effectiveness and patient safety.11 Patient experience is also considered the most effective quality measure of patient centredness, which is defined as providing care that is respectful of and responsive to patient preferences, needs and values.11 When patient experience is positive, health outcomes improve with better patient behaviours, treatment adherence and healthcare resource use.11

    To measure multidimensional patient experience, a robust, reliable, valid and responsive instrument is required which assesses all quality-of-care dimensions. A systematic review (submitted for publication) conducted by these authors revealed that numerous instruments are available,12–15 but they have many deficiencies including insufficient quality and psychometric properties, heterogeneous construction which does not cover all aspects of primary care, poor validity and feasibility, inability to measure change and wide variability. Furthermore, many of them measure patient satisfaction which provides a limited view of care as an experience and does not enable potential improvements to be assessed. Furthermore, few studies have focused on both patient and carer experiences, most focus on either patients or GPs.16–18 A previous systematic literature review revealed that no studies explored the patient, carer and HCP perspective regarding quality of care19 20 and no instruments exist which examine the carer experience alongside that of the patient and HCP or assess the patient’s role in managing their condition. Yet to fully understand the management issues and appropriately address and improve quality of care in MPHCCs, all stakeholders in patient care must be involved.

    Patient care experience is increasingly seen by healthcare providers, administrators, policy-makers and patients themselves as a judgement of quality,21 where negative evaluations indicate the need for improvements. Patients have important insights into delivery of care that healthcare providers cannot assume. Healthcare providers often subjectively perceive the patient’s needs and experiences and these perceptions can prove incorrect. Systematically gathering information on patient needs and experiences, using methodologically sound instruments such as validated questionnaires, should therefore be an integral part of routine primary care.22

    This study aimed to explore care experiences in MPHCCs from the patient, carer and HCP perspective. The aspects found during this study will be used in the next phase of the project to create a patient reported experience measurement tool to address the deficiencies present in existing instruments.

    Method

    Design

    This qualitative study was performed in five MPHCCs, in France, between March 2017 and December 2018. The study was designed by a team of senior researchers in sociology and primary care.

    Face-to-face, in-depth interviews were conducted with patients and carers together and HCPs separately. An additional focus group to discuss the centre’s organisational structure was conducted in each MPHCC (including at least the GPs and nurses).

    Sample

    Participants were recruited through purposive sampling. Patients varied in gender, age, chronic conditions, HCP type and the presence or absence of a carer. Carers were invited to participate if they were currently supporting the patient. For HCPs, the goal was to include one representative from each profession per MPHCC. Patient, carer and HCP recruitment stopped at data saturation (regarding SRQR criteria (Equator)).

    Patients with multimorbidity (at least two chronic conditions) who were monitored by a GP and another HCP from the MPHCC were included. Patients with a condition affecting cognition (Mini Mental State<23) were excluded.

    The GPs from each MPHCC approached patients meeting these inclusion criteria during their consultation. The investigator (GP or final year medical students) contacted the patient by telephone to explain the aim and focus of the research. HCPs were contacted by telephone or email. No-one refused to participate, and informed consent was signed by all interviewees.

    Patients chose whether to be interviewed at home or in an MPHCC meeting room, while HCP interviews took place in the MPHCC. All interviews were conducted once face-to-face by an independent GP, assisted by medical students, and an independent sociologist (PhD), who were of either gender, and all had experience in qualitative research and interviewing.

    Interviews were only audio recorded and transcribed verbatim by a transcriptionist. Verbatims were returned to participants for approval.

    Data collection

    Two interview guides were developed by the research team: one for patients and carers (online supplemental data 1) and one for HCPs (online supplemental data 2). Prior to use they were tested between members of the research team to ensure they were easily understood. The interview guide has been adapted over the course of the first interviews. Interviews were conducted in French and translated by a native English speaker (Charlotte Wright BVM&S MRCVS DipTrans of Speak the Speech Consulting).

    Patient and carer interviews lasted between 30 and 90 min, HCP interviews lasted between 26 and 120 min and the focus groups lasted between 90 and 150 min.

    Field notes were made on the participant sociodemographic characteristics and MPHCC organisational structure.

    Analysis

    Two different researchers per MPHCC coded the verbatims. Four members of the research team conducted blind analysis of the codes using an inductive approach in a content analysis perspective23 24 by reading the text and organising it into core categories. Results were pooled and emergent categories pertaining to aspects from the patient and carer perspective were discussed. The coding book was regularly presented and discussed with the research team. Category denominations were refined, and disagreements were resolved consensually. A description was written for each aspect detailing the key features. Qualitative data analysis followed the coding paradigm of the grounded theory method. Open coding was conducted initially to break the textual data into discrete parts. Next, axial coding made connections between the codes and then selective coding was used to select one central category connecting all codes.

    The constant comparative method25 was used to highlight data consistencies and variations by looking for connections within and across focus groups, interviews and codes. HCP analysis was performed initially and then the patient views were mapped enabling direct comparison between the two. Five syntheses (two for patients and family carers, two for HCPs and one global) were issued by five senior researchers (two primary care researchers and three sociologists) working blind and pooling their data at each synthesis step.

    We considered data saturation achieved when no new codes emerged from verbatim analysis. This occurred after the 55th interview and 4th focus group in the HCP group, and after the 24th interview in the patient and carer group.

    Results

    Fifty-seven HCPs were interviewed representing 11 professions and 5 focus groups were conducted (table 1).

    View this table:
    Table 1

    Healthcare professional characteristics

    Twenty-six patient interviews were performed, 23 of which included a carer (table 2).

    View this table:
    Table 2

    Patient characteristics

    Nine core aspects were identified, each being relevant for both patients/carers and HCPs with some detailed nuances. Table 3 provides a summary of each aspect and its features.

    View this table:
    Table 3

    Aspects and corresponding features

    Having accessible, available and varied care

    Patients and HCPs highlighted that accessible care was an element of quality care. This starts with making an appointment. Patients preferred the physical presence of a receptionist as many felt uncomfortable with new technologies. Then, MPHCCs enable patients to have joint consultations with different HCPs in the same centre. Also, patients appreciated being able to group consultations on a particular day, which limits the number of times the patient visits the centre. Offering home visits for those unable to travel was also important.

    Feeling welcome and enjoying comfortable, well-equipped, and clean premises

    Patients appreciated well-maintained premises with a welcoming receptionist and entertainment in the waiting room. They emphasised the importance of soundproofed rooms and a layout to guarantee confidentiality, especially for psychologist consultations. HCPs reiterated the importance of confidentiality.

    Having quality medicotechnical care (medical knowledge and technical skills)

    Staying at home, or reducing the need for medication or hospitalisation, were major concerns for patients. HCPs discussed complementarity of the different professions, which is essential for comprehensive and effective patient care.

    Patients stated that the speed and quality of diagnosis, and therapeutic management were important. HCPs stressed the importance of following recommendations and updates.

    Patients highlighted that a dynamic GP performing diagnostic re-evaluation, further examinations, and monitoring chronic conditions improved quality of care. When the diagnosis was in doubt, patients appreciated undergoing further examinations, being referred quickly to a specialist, and being informed rapidly about the results.

    HCPs mentioned equipment being available within the MPHCCs for managing life-threatening emergencies and stated that effective care should also reduce emergency service use. Patients pointed out the lack of physical therapy equipment.

    Having a reliable GP

    Patients valued thorough clinical examinations and other GP skills including knowing about the patient and their preferences, beliefs, wishes, and their medical, social, and family history.

    Furthermore, GPs helping with administrative tasks such as completing chronic condition applications (providing 100% reimbursement for any treatment linked to the condition), applying for transport vouchers, and making appointments with specialists or other medical professionals was appreciated. However, HCPs did not mention this.

    Receiving appropriate care from HCPs other than the GP

    Patients and HCPs mentioned the competency of HCPs other than the GP. It was mainly reflected in the nurses’ consideration of pain and cleanliness.

    Respecting protocols was particularly important for HCPs. Patients focused on the importance of the other HCPs respecting prescriptions, monitoring their condition, and keeping the doctor informed and updated. This was reiterated by the HCPs.

    Maintaining an efficient relationship with HCPs

    Both patients and HCPs explicitly highlighted the central role of an efficient HCP relationship as a key element of quality care.

    Patients and HCPs agreed on the need for a trusting relationship, which HCPs felt was promoted by working in a common care structure. This trusting relationship seems to be based on listening carefully to one another, paying attention to the patient, and communicating easily. In addition to attentive listening, patients also described the importance of empathy, respect and ensuring both the patient and carer are given the same information without contradiction.

    Importantly, HCPs described the way communication had changed since working in an MPHCC, particularly the ease of obtaining a colleague’s opinion and the opportunity to approach things differently to provide patients with quality care. This concept was not described by the patients.

    All participants highlighted the importance of maintaining and respecting confidentiality, particularly within the secretarial office, and respecting the patient’s consent to share information about them within the MPHCC.

    Benefiting from organised and coordinated care

    Patients and HCPs agreed on the importance of continuity of care within the centre, underpinned by easily shared medical files, secure messaging, or report books at home—all of which are elements of quality care.

    Although HCPs insisted on the permanence of care, which they felt was improved by creating MPHCCs with substitute doctors available in cases of absence, they emphasised that patients preferred stable follow-up with the same doctor and mentioned that some patients struggled to adapt if the HCP changed. Patients and HCPs wanted more continuity of outpatient care within the centre.

    Participants agreed that coordinated care, made possible by interprofessional communications or multiprofessional consultations was necessary. HCPs described learning to work together, for the patient, by sharing a common work structure, resulting in homogeneous discourse to promote therapeutic education and alliance. The patients also highlighted this notion, emphasising the benefits gained from the care protocols and pooling of knowledge.

    Notably, patients felt this support was reassuring for HCPs, and, conversely, the latter found it reassuring for patients and their carers.

    Despite patients and carers sometimes being unaware of the whole range of care the MPHCC offered, they emphasised the importance and advantages of this diversity, as did the HCPs.

    Although HCPs discussed interprofessional relationships more, patients also valued them and felt they impacted their quality of care.

    Being an informed, supported and involved patient

    Patients, carers and HCPs all agreed that informing patients about their condition, treatments, outside help or discussions between professionals are essential elements of quality care.

    Patients and carers particularly emphasised the psychosocial impact the condition has on the patient’s life. This appeared to be a quality-of-care criterion and was based as much on the psychological repercussions linked to the condition and the loss of autonomy as on the impact on housing and employment.

    Carers also highlighted the importance of patient support and the need for psychological support, whether through referral for psychological treatment or the doctor providing it themself. Patients emphasised the importance of implementing and reassessing home support workers, but HCPs did not discuss this concept as much.

    Patients and HCPs agreed that a beneficial therapeutic alliance in which patients participate in their health through shared medical decisions and are involved in their treatments and future is essential. Patients felt that patient-centred care was essential with their wishes and needs being considered.

    HCPs felt the objective was to help patients become independent, particularly through therapeutic education. Patients agreed as it allowed them to acquire knowledge and benefit from the group dynamics which are inherent in this form of practice.

    Having an informed, supported and involved carer

    HCPs and patients reported that carer involvement is essential. They agreed that considering the carer’s opinion when discussing treatments or the patient’s future was an essential element for providing quality care. Having the carer present during consultations or home visits was particularly important as was the carer’s role in organising care, which is essential in home settings.

    Patients and HCPs agreed on the value of the carer receiving information and therapeutic education to ensure coordinated care and on the importance of carer support. Patients emphasised providing psychological support and home help for the carer but HCPs emphasised the support provided through the multidisciplinary nature of the centre; a concept absent in the patient interviews.

    Carers highlighted the repercussions that the patient’s condition had on them, particularly the impact on their social life, hobbies, and daily living activities especially when the patient refused care. HCPs also discussed this.

    The importance of providing information about financial support and help available to carers was only mentioned in the HCP interviews. The notion of carers trusting the HCPs emerged throughout the interviews.

    Discussion

    Summary

    This study provided a new perspective by interviewing and considering carers alongside the patient and HCPs which has not been done before. Our study highlighted some new areas of interest and features which have barely been described previously.19 26–29 These include MPHCCs enabling HCPs to have meetings quickly and easily and enabling patients to have joint consultations with several professionals at once. Furthermore, patients greatly appreciate the skills of other professionals within the centre, besides the GP. To our knowledge, no other questionnaire has explored these aspects relating to the other professionals. Organisational elements were also raised, possibly linked to the concerns about medical desertification.

    Comparison with existing literature

    Patients, carers, and HCPs agreed on all the aspects and their features but with slightly different perspectives. Having accessible, available and varied care was an important aspect for all participants, particularly patients, even though some mentioned it was occasionally difficult to see their GP outside of normal consulting times. Patients highlighted the importance of features such as drop-in consultation slots and a physical desk with a receptionist for guiding, directing and reassuring the patient. Feeling welcome and enjoying comfortable, well-equipped, and clean premises was also an important aspect for all participants.

    For the aspects having a reliable GP, receiving appropriate care from HCPs other than the GP and maintaining an efficient relationship with HCPs, all participants agreed that the most important features were empathy, clear communication and confidentiality. This confirms what has been found in previous studies.28 29 Features highlighted as promoting good quality of care were communicating easily with HCPs, a relationship of trust and being a good listener.

    The role of the GP is fundamental to ensuring quality of care,29 while organised and coordinated care are also essential.30 31 HCPs focused more on coordinated follow-up while patients and carers wanted stability within the healthcare team. However, this could be the same thing since coordination relies on stability. Patients with multimorbidity often require hospital care in addition to primary care thus excellent cooperation and coordination between hospital and primary care staff is essential to ensure quality of care. This is further enhanced by good coordination between the primary care team.32

    Every participant emphasised that patient and person-centred care were essential for quality which is consistent with a previous study.33 However, the present study provides more extensive information than previous studies about the importance of providing patients and carers with appropriate medical information.28 34 Providing patients and carers with therapeutic education and ensuring they are informed, listened to, involved and supported in all aspects of care appeared essential and were extensively discussed. The common goal was ensuring patient autonomy through clear and consistent information. HCPs also emphasised the importance of support for carers.

    There are few patient reported experience studies concerning the medicotechnical dimension of care so the present study provides a new perspective on this aspect which has not been previously described. It confirms that patients not only value HCP technical skills but also the human aspects including receptionist assistance, the doctors and nurses being good listeners and the physiotherapist giving encouragement. However, discrepancies concerning quality of medicotechnical care were revealed which is consistent with existing literature.28 Specifically, HCPs insisted on evidence-based-medicine and recommendations whereas patients and carers looked for efficient care and improvements in their health.

    Going beyond the data in the literature,35 carers particularly highlighted their role. Previous studies have reviewed elements of the carer role but were mainly limited to providing information and support. The present study reveals information about their role in helping patients remain autonomous which supports concepts highlighted in recent scoping reviews.35–38 In complex care situations, carers are essential. They not only need to support and care for the patient, who is dependent on them, but also continue their normal social, family, and professional life. Once HCPs accept the carer role, they can fully engage in patient care. Carers improve the therapeutic relationship between the patient and HCP and sometimes enable patients to remain at home and avoid hospitalisations.

    Prevention was never cited as important for quality of care in this study which contradicts data from the literature.39 This may be because this study focused on patients with multimorbidity whose care focuses on management of their chronic condition rather than prevention. It could also be due to the absence of this specific point in the interview guide which concentrated on the patient and their condition, not public health. Prevention is present in many quality of care scales and indices19 but was not identifiable in this study.

    Strengths and limitations

    This study did have strengths and limitations. Selection bias was limited through purposive sampling and participant diversity. Information bias was limited by the number of researchers, blinded analysis, data pooling within the research team and the mixed culture of a sociologist research team working with a primary care research team. Social desirability bias could have been present with participants providing information they felt was more desirable or acceptable rather than their true thoughts or feelings, possibly resulting in information loss. Information may also have been lost since patients and their carers were interviewed together so they may have been more candid. Confusion bias in this study should be minimal due to the multiprofessional nature of the interviews, the number of analysts and their perspectives and the mixture of individual interviews and focus groups. Interviewer bias may have been present as the interviewers were interested in evaluating quality of care and some interviewed HCPs had previously met the interviewers through their university roles.

    Conclusion and implications for future research and practice

    This study reveals that patients, carers, and HCPs share a common vision to improve the quality of primary care through nine core aspects. The present study is the first to present an exhaustive picture of HCP, patient and carer experiences. It also reveals new areas of interest such as features relating to the multidisciplinary nature of the centres, appreciation of other professionals within the centres, medicotechnical dimensions of care and the carer role in helping patients remain autonomous.

    This unique study considered patient, carer and HCP experiences which provided a more comprehensive overview of these perspectives, thus enhancing insights from previous studies.

    This enhanced knowledge improves understanding of these quality-of-care aspects and their associated features and can guide efforts to implement MPHCC evaluation tools that truly reflect patient and carer needs and enable an efficient experience in terms of quality.

    Existing questionnaires all have deficiencies, and a robust, reliable, valid, and responsive instrument is required which can be used to evaluate and improve health service provision and quality. To address these deficiencies, the new perspectives found in this study will be added to former aspects to create a comprehensive quality of primary care evaluation tool aimed at improving MPHCC quality.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this article and in its online supplementary material.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Ethics committee approval was obtained by the local ethical review board (Comité éthique de Brest, No. 2016.CE33). The study was conducted in accordance with all French regulations. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We would like to thank the interns who participated in the data collection: Camille Stouff, Annabelle Hoffnung, Margaux Sei, Marie Dohollou, and Marine Carton. Florian Pédrot, sociologist, who also took part in the data collection (préviously at LABERS). This article is supported by the French network of University Hospitals HUGO (‘Hôpitaux Universitaires du Grand Ouest’). Editorial assistance in the preparation of this article was provided by Speak the Speech Consulting.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Contributors JD and J-YLR conceptualised this study. JD wrote the draft. MB and J-YLR supervised the manuscript. JD, DLG and GF analysed the data. FLB and J-YLR inspected the quality of data. MB and J-YLR managed the overall design of the study. All authors approved read and approved the manuscript. JD is responsible for the overall content as the guarantor.

    • Funding This study was funded by the DGOS, PREPS-15-000472, QualSoPrim. They had no role in designing the study, collecting, analysing, or interpreting the data, writing the manuscript, or deciding to submit the paper for publication. Brest University Hospital is the sponsor for this study (DRCI CHRU Brest, Morvan Hospital, Avenue Foch, 29200 Brest). There were no constraints on publishing.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.