Factors influencing GP provision of self-care information for minor illnesses: A qualitative study

Author

Jennifer Bishop

Abstract

background

Being provided with self-care information has been shown to increase knowledge and confidence in patients participating in self-care. However, little is known of GPs’ experiences when providing self-care advice to patients for minor illnesses, and what factors influence the provision of self-care information.

aim

To explore GPs’ views and experiences that influence the provision of self-care advice/information to patients presenting with minor illnesses.
design and setting: Qualitative study using in-depth interviews with 9 GPs in a busy, inner-city medical practice.

method

GPs from one medical practice were invited for interview. The interview guide explored their views and experiences of providing self-care information. Interview data was analysed using thematic coding and by written interpretive summaries.

results

Self-care advice/information was provided as a matter of judgement but is influenced by GPs’ personal preferences and type of minor illness. GPs’ views regarding the patient’s character, age, self-efficacy and cognitive ability, influences their provision of information about self-care. Time has been identified as a major influence that hinders the provision and documentation of self-care, although it is acknowledged that investing time in self-care can bring benefits for the future.

conclusion

The provision of self-care information is inconsistent amongst GPs. More time permitted for the consultation may facilitate the provision of self-care. Further resources need to be identified to enable the provision of self-care information for non-English speakers as currently this is inadequate and may hinder self-care. There are no known policies to guide GPs in providing self-care, and scope exists for development of national guidelines to assist healthcare professionals when providing self-care information.

Full Article

introduction

The ever-increasing need for efficiency savings in the United Kingdom (UK) National Health Service (NHS) necessitates change towards a more cost-effective, integrated and resilient system of care1. Empowering people through the concept of ‘self-care’ can reduce the demand for GP consultations, freeing up time to care for patients with more complex needs and allowing money to be spent in areas where it is most needed to improve health outcomes2. The Self-Care Forum2 define self-care as the actions that individuals take for themselves, on behalf of and with others in order to develop, protect, maintain and improve their health, wellbeing or wellness. The International Self-care Foundation’s (ISF) ‘seven pillars of self-care’ framework3 provides a more holistic description of self-care that includes the full range of self-care activities (illustrated in appendix 1). To discuss the framework is beyond the remit of this paper but essentially, it illustrates all the health promoting behaviours that a person can undertake in order to self-care. Of particular relevance to this paper, is the seventh pillar of the self-care framework3 which constitutes the rational and responsible use of health products and services in order to safely and effectively manage their own health. This includes people’s ability to manage everyday minor ailments or conditions.

Minor illnesses impact highly on healthcare resources within primary care, as patients attend for consultations when they may be able to self-care without needing to see a healthcare professional4. The UK government encourages self-care for minor illnesses and has taken measures by enhancing the role of community pharmacists to provide advice and guidance, as well as the reclassification of some medications that can be purchased over-the-counter (OTC)5,6. A paper by the Self-Care campaign group emphasises the importance of self-care in order to manage the demand for NHS services for future sustainability7. Healthcare professionals play an important role in promoting and encouraging self-care for minor illnesses and education should be given whenever possible5,7.

A small-scale audit was conducted by the researcher to investigate the provision of self-care information by GPs in the workplace. Based on the top ten minor ailments that account for 75% of all consultations (appendix 2)4, key observations from the audit highlighted that self-care advice is not always provided or recorded in the patient’s medical records. Furthermore, the provision of self-care information/advice varied between clinicians for the same complaint in terms of what and how information is provided. Literature on the provision of self-care information by clinicians is currently limited. This study explores what influences GPs to provide self-care advice for minor illnesses. A better understanding on the views and experiences of GPs may identify the theoretical drivers that enable or hinder the provision of self-care advice/information to the patient. The study helps raise awareness on the importance of increasing self-care and highlights improvements in the process.

Method

Description of the setting
The setting for this study was a busy inner-city medical practice, serving a multi-ethnic population of approximately 16,000 patients.

Sampling and procedure
All qualified GPs employed at the participating surgery were eligible for inclusion. Each participant was provided with a letter clarifying the purpose of the study, with an invitation to a 45-minute audio-recorded interview exploring the provision of self-care information for minor illnesses. To preserve confidentiality and anonymity, GPs were assigned a unique identifying number and assured that they could withdraw from the study at any time.

The interviews
Qualitative, face-to-face interviews were the chosen method to collect GPs’ views and experiences. An interview guide ensured that important topics derived from the literature review, researcher’s observations and previous studies4,8, were covered in each interview. The interviews were designed to elicit interviewees’ knowledge on self-care information, as well as their influences for its provision, while remaining flexible for participants to raise issues pertinent to them. Interviews were audio-taped and transcribed verbatim by the researcher and administrative clerk. A sample was later checked against the recorded interview to ensure transcription accuracy.

The time the study took place
The interviews were undertaken during a six-week period in the autumn of 2016. They were conducted at the GP surgery between morning and afternoon sessions, to minimise disruption of surgeries.

Analysis
A descriptive account of the data was initially generated to capture GPs’ perspectives, and then interpreted to provide emerging themes to understand the phenomena9. Braun and Clark’s10 six-step analysis approach was utilised to structure the analysis process. The six-step analysis began with listening to the interviews, followed by in-depth reading and re-reading of the transcripts to become intimately familiar with the interview data10. Once fully immersed in the data, key words, ideas, patterns and quotes were manually highlighted and colour coded to produce an initial list of relevant and interesting features of the data. Following the initial coding, patterns were identified and the items were collated into themes. The themes were reviewed and refined to ensure accurate representation of the data. The next step was to define and title each theme. The final step of Braun and Clark’s10 approach was to document the findings. Exemplary quotations from the transcribed interviews were used to illustrate the key themes and contextualise it in relating to the current literature.

results

Participants
All GPs working at the surgery were invited to participate (n=10), consisting of nine GP partners and one locum GP. Ten GPs agreed to participate and 9 (aged 34-60 [median age 47 years], representing both sexes) were interviewed before data saturation was reached. Two further participants, a medical registrar and Nurse Practitioner (with minor illness experience) agreed to conduct pilot interviews, which enabled improvements to be made to the topic guide and interview format. In the interviews GPs recounted their experiences, views and behaviours on self-care for minor illness, and several themes emerged from the data.

Defining minor illness and self-care
To allow data to be placed in context, GPs’ knowledge of minor illness and involvement of self-care was explored. GPs described their understanding of minor illnesses:

Self-limiting, may not require treatment, conditions will often get better on their own.’ (interview 2:2)

‘…it wouldn’t result in significant harm or shorten their life expectancy.’ (interview 4:1)

When describing minor illness, some GPs offered a list of ailments that they perceived to be minor illnesses. There was also an element of assumption by the researcher, for example, in the following exemplary extract:

‘…there’s schemes for that [minor illness] isn’t there…but I mean it’s like coughs and colds, thrush, threadworms…you know…cradle cap…’ (interview 5:3).

Defining self-care in relation to minor illness highlighted wider (and often varying) interpretations between GPs:

‘…anything provided and done by the patient up to the point at which they’ve had an appointment with a medical professional, in order to manage their symptoms…’ (interview 4:1)

I define self-care as within the family. I was going to say patients dealing with their own illness without reference to anyone else but I suppose…dealing with it at home with family or friends help if needed.’ (interview 1:1)

However, it was noticeable that GPs attached great importance to medicines and drug management in self-caring for the minor illness:

Watchful waiting…making sure you [the patient] do access the chemist for over-the-counter treatment depending on what it would be…before accessing the doctor.’ (interview 3:2)

Crossover with chronic illnesses
There was crossover with chronic illness as GPs explained that patients attending with minor illnesses frequently have additional comorbidities which tended to influence the provision of self-care information. An exemplary extract:

‘…you have someone with Chronic Obstructive Pulmonary Disease who gets a cold regularly…you would want to advise on having the flu vaccine, hand washing, treating the cough early, use of inhalers…in order to prevent a minor illness from becoming worse.’ (interview 8:6)

GPs’ role in providing self-care for minor illnesses
All GPs expressed positive support for self-care and perceived that it involved: teaching and education to empower patient’s knowledge and confidence; and encouraging the use of pharmacists for OTC medicines. Some participants believed that questioning the patient on what steps had already been taken towards self-care, stimulates expectation to manage future minor illnesses. Some GPs viewed self-care as integral to their role and it was their duty as a GP.

I think it’s our bread and butter really…explaining conditions to patients and how to manage them is just what we do.’ (interview 8:7)

‘…my job is to explain so that they do know that they are not going to die from a minor illness.’ (interview 1:1)

Patients are not doctors so they don’t know’ (interview 3:4)

Self-care was generally acknowledged by most GPs in the wider context but attitudes varied:

I think the NHS can’t cope with the burden of patients not being able self-care, we don’t simply have enough healthcare professionals to cope with the demands. I think it’s [self-care] something we have to do to try to manage our resources and manage our workload, so I think it is something which is important.’ (interview 4:7).

I don’t think it’s [self-care] the be all and end all. I think there is the impression from some quarters that it will solve the NHS crises, which I don’t believe because I think it’s more to do with the breakdown of the wider family in society…’ (interview 9:3)

…and not all GPs believed that self-care was useful in all cases:

the patient is going to get better whatever we do. It’s unlikely anything I say is going to make any difference to how quickly they get better or not. If it means that they are more able to cope with similar episodes in the future without coming and seeking help, then it’s useful but…sometimes it’s a complete waste of time.’ (interview 1:6)

Methods of self-care advice
GPs showed individual preferences towards the methods of providing self-care advice. Some GPs viewed verbal advice as being more effective than written information:

I think patients listen to what you’ve got to say…more than anything you write down for them. I think often, particularly leaflets in the waiting room just get thrown away or ignored…but I think if you specifically say something to a specific patient they tend to listen.’ (interview 8:4).

and later:

I think you have to keep the message simple and repeat the same messages’. (interview 8:4)

However, some GPs believe that written information together with verbal advice is beneficial:

they [patients] can’t always remember what you’ve said…if its written down then I think it [self-care] is quite useful’ (interview 3:8)

Back pain was a commonly cited example whereby written information was frequently used to assist in explaining back exercises. Viral illnesses were commonly a cited example, for the least provided written information. Some GPs had their own sources of information which they have compiled themselves (interview 2), whilst others used electronic means:

the links on the computer system are really helpful because that makes it a lot quicker to find an appropriate leaflet and appropriate information for the patient.’ (interview 2:2)

In the following exemplary extract, the GP adds a caveat to providing written information:

I don’t like to just hand them a leaflet and say read that because I think most people don’t. I would rather point out in this leaflet, it tells you this, and use it as a kind of visual aid in the consultation but it takes time.’ (interview 9:4)

Some GPs described the benefit of demonstration and instead viewed leaflets as an adjunct to offering advice. The type of minor illness influenced their decision on the method of self-care provided:

For a frozen shoulder you give them the leaflet and show them the exercises – I usually asterisk three and say do these at the moment and maintain the mobility in your shoulder…’ (interview 9:9)

Internet and the media
GPs held mixed views on the internet, and expressed caution for its use as a resource:

There’s the internet… which has some dodgy information as well as some good information…my role is to tell people about the good internet websites…so they may refer to them in future rather than come back to see you.’ (Interview 2:1)

I don’t use the internet beyond recommending patient website [www.patient.co.uk] which is simply a source of leaflets. I don’t find it [the internet] all that helpful.’ (interview 1:2)

The media was generally perceived to be a barrier to promoting self-care and most GPs believed this added to their workload through increased patient anxiety (interviews 1-9):

I think the media have an effect on inflaming the worried well’ (interview 8:8)

Judgement and habit
Self-care advice was provided as a matter of personal judgement. GPs were unaware of any policy or procedure to guide clinicians on the delivery of self-care:

I don’t have a routine that I always give a leaflet for this [minor illness] …so I often ask people ‘would you like a leaflet about it’. And I don’t want to waste my time or theirs, or paper giving them one if they are not going to read it…other people you will go with your past experience of whether they’re interested in that.’ (interview 9:5)

Another GP reported that it was a matter of habit whether written self-care information was provided or not.

it’s more remembering and thinking about it [self-care] as a possibility I suppose…I haven’t got into the habit of using them [patient information leaflets]…’ (interview 2:6)

Patient influences
The patient is a major influence in the delivery of self-care information. GPs recalled that age, social background/circumstances, social/family support, personality, intelligence/mental capacity, motivation, co-morbidities, culture, language spoken, health anxieties, and requests for sick-notes, all influenced their decision to provide self-care information (interviews 1-9):

‘…I would check what they have done already and from that you can gauge what they know…whether they have taken the appropriate step already so I can tailor my information so I’m not repeating what they already know.’ (interview 9:8)

‘…the patient’s level of intelligence is going to alter how you communicate it [self-care], how simple you keep it, how much depth you go into. Often somebody who is more intelligent and more educated I would provide actually less detail because I’ll know that they’re more likely to actually find the right information themselves’ (interview 9:8)

Another GP:

I think every patient is an individual…so you have to tailor every consultation according to the individual needs. So, I might say how does a patient affect what you’re doing, I think it has everything to do with how you manage self-care’ (interview 1:2)

and later:

body language, ordinary language, past medical history is very important. When in doubt listen to the patient, listen to their agenda, ultimately it’s about speaking to them…you’ve got to look for hidden agenda because minor illness may be a code word for a reason for coming with something much more significant’ (interview 1:2)

Although one GP warned about generalisation, young people were perceived by most GPs as indifferent to self-care whereas elderly people were more proactive:

there are a lot of particularly young people who are so used to instant results these days, they don’t know how to self-care for minor conditions’ (interview 2:2)

elderly people self-care more perhaps because they didn’t have such good access to healthcare when they were younger… however sometimes I have to tell them they shouldn’t self-cared’ (interview 5:2)

Patient confidence can instil caution and therefore prove inappropriate for the patient to self-care, as illustrated in this extract:

young, single, mums with babies…if I’m worried about them…I wouldn’t necessarily just say to self-care, I would probably bring her back the next day for review…because they don’t always have the confidence to ring the doctor back if they’ve already been seen…’ (interview3:6)

Culture and language barriers
GPs acknowledged a lack of written information for patients presenting from different cultures and languages, and this often hindered the provision of self-care information.

I would be surprised if the amount of self-care advice that I give is the same for an English or non-English speaker, purely on the basis of time and access to resources… the challenge of culture and language is a potential barrier and I don’t yet see solutions that are practical to do to deal with that.’ (interview 9:9)

Patients reactions to self-care
When asked about how patients reacted to providing self-care advice, GPs gave mixed reactions. The manner in which the patients reacted sometimes influenced the provision of self-care information;

all sorts of reactions from gratitude, acceptance, delight that I’m not prescribing an unnecessary medication, delight with the reassurance I give them, to absolute hostility as well, as I’m not giving them a medicine they regard as necessary.’ (interview 1:6)

Some GPs believed the presentation of self-care influences its value and response by the patient:

They [patients] don’t mind when I promote self-care because I try and present it in a good, positive way for them.’ (interview 3:5)

GPs found it difficult to recount negative experiences of providing self-care advice/information and limited examples were provided. An exemplary extract:

well unless you count patients being cross and go storming out of the door and being rude… that’s quite a common thing. But clinically wrong, I’m struggling to think of anything actually.’ (interview 1:8)

Time
Insufficient time for consultation was by far the most commonly cited obstacle in providing self-care information (interviews 1-9):

patients come in with three problems, they want us to deal with all three of those in ten minutes and sometimes they are very complicated...’ (interview 8:5)

encouraging patients to self-care can actually be a longer consultation…’ (interview 2:2)

…if I’m under time pressures I would certainly treat rather than advise on self-care to save time…’ (interview 1:3)

Time and resource constraints were echoed by two GPs:

…I mean that it [self-care] doesn’t take very long but everything adds up. If you have to give them a leaflet, you have to search for it…’ (interview 9:4)

time restraints are waiting for the computer to kick in and to print the leaflet out’ (interview 3:9)

Conversely, one GP suggested:

I would like to view [self-care] as an investment, if I do it now then maybe I will be saving appointments in the future.’ (interview 9:5)

Pharmacy and prescriptions
Most GPs encourage self-care through counselling and promoting OTC medicines, rather than offering a prescription. Some encouraged the use of pharmacists for advice whilst others did not, citing a conflict of interest from the pharmacists’ role to sell medicines. Delayed prescriptions whereby, if there is no improvement, the patient can obtain antibiotics without the need for a GP consultation11 were viewed by some GPs as positively encouraging self-care. Free prescriptions were perceived as having a negative effect, as patients that were attending for this were perceived as being less likely to self-care, and the GP was less inclined to provide advice:

if the patient is really interested in looking after themselves, I’ll use them [leaflets], but if they [patients] just want tablets, they probably won’t use them.’ (interview 1:2)

Documentation
Documenting self-care was inconsistent between GPs, with some stating that verbal advice was (often) given without being documented due to either time pressure (interview 9:8) or forgetfulness (interview 2). Some GPs used resources electronically with the benefit that if it is printed, it is automatically documented in the medical notes (interview 2,4). Overall, the advice provided was often unspecific and ambiguous, for example:

usual advice given’ (interview 8:11)

Or

‘review sos’ (interview 1:7)

discussion

Summary of main findings and comparison with existing literature
This study addressed what influences GPs to provide self-care advice for minor illness. Previous studies have broadly described experiences and knowledge on self-care for minor illnesses, from the patients’ perspectives12-17, and studies examining healthcare professionals’ perspectives are relatively sparse8,17,18. GPs viewed it as their role to educate patients in self-care7, although differing views remain as to what constitutes a minor illness19. GPs perceived minor illnesses as being common, uncomplicated, self-limiting11,20, do not require hospitalisation17, and if left untreated it rarely implies complications15, whilst other GPs listed specific ailments. The type of illness heavily influenced what, and how self-care advice was provided. Furthermore, there was recurrent crossover with chronic illness, possibly due to self-care being a common management strategy for long-term conditions7,21, and patients presenting with minor illnesses may have additional co-morbidities5 which in turn may affect the information provided. However, with an ageing population and more people living with chronic ill-health22, there is a sense that promoting self-care for minor illnesses can lead to benefits in terms of patients being better equipped to self-care with future chronic illness.

When describing self-care, GPs in this study suggested that it included: the care that people do for themselves to maintain their own health, wellbeing and prevention of disease23, and the care provided by family, friends and communities24, without the need for seeing a health professional25. However, self-care includes the support provided by health professionals and involves empowering people with the knowledge and confidence to take responsibility for their own health and wellbeing17,26. Rather than delegating ‘self-care’ responsibility to the patient, clinicians should ‘support self-care’ through effective communication, negotiation and patient-healthcare professional partnerships27. Noticeably, GPs placed great emphasis on accessing chemists for advice and OTC medicines. However, self-care is much more comprehensive than just focusing on the medical and drug management aspects of self-care and incorporates all aspects of promoting healthy behaviours.

The ISF seven pillars3 framework recognises that unhealthy behaviours (for example, smoking, excess consumption of alcohol, poor diet and insufficient exercise etc) tend to ‘cluster’ together in individuals and in particular parts of a population. ISF3 proposes that if a person is motivated towards one healthy behaviour then they may embark on other healthy behaviours, therefore reducing the disposition of partaking in risk-taking behaviours. With the exception of self-care for chronic illness, there was little mention by GPs during this study of self-care in relation to other health promotion aspects or activities of self-care. This may be because GPs concentrated on self-care related to minor illnesses, knowing that this was the main focus of the interviews, and did not consider the wider aspects of self-care and its relationship with other health promoting behaviours. Alternatively, GPs may be cautious when providing self-care advice as concerns about falling victim to the compensation culture may discourage them from promoting self-care in their consultations11. However, this was not found to be the case in this study as GPs generally viewed self-care positively with little to no clinical risk.

Other factors that may hinder GP self-care provision include time constraints during consultations with insufficient time to promote self-care on issues other than minor-illness itself4,28. Indeed, GPs spoke of their personal judgement when providing self-care advice, and repeatedly emphasised that time was the leading constraint that influenced whether advice was provided during a consultation, or subsequently documented in the medical notes. GPs in this study supported the view that that self-care is good in theory, but felt they did not always have the time to implement it, despite awareness that it can reduce demand, and consequently, workload28. A report by The King’s Fund ‘Understanding pressures in General Practice’29 recognises time scarcity, compounded with the fact that the work is becoming more complex and intense as major pressures for GPs, and when GPs are feeling pressured and overwhelmed, time to educate patients in consultations is reduced. There have been discussions about raising GP consultation times to increase patient safety and quality of care4,30. Extra time allows for improved decision and case management, therefore reducing the administrative burden outside clinical times, as this can be facilitated within the consultation30. Additionally, there would be increased time for GPs to encourage self-care and provide information within the consultation. However, with increasing GP workloads, a shortage of GPs, rise in patient expectations and an ageing population meaning that demand will continue to grow1,22,31,32, it is unlikely that practices have the capacity to lengthen appointment times and maintain the same levels of clinical contacts per week30.

In addition to time constraints, the healthcare professional’s fear of empowering the patient may hinder clinicians’ willingness to encourage self-care33. This resonates with Bourdieu’s theoretical concept of ‘habitus’34, which describes a set of learned ‘dispositions’ such as; medical training and education that becomes second nature and embodied within the GP. These ‘dispositions’ generate practices, perceptions, behaviour, and attitudes that reflect the social conditions (e.g. medical training) within which they were acquired35. In this present study the GP participants varied in age, experience, and ‘dispositions’34. GPs acknowledged that patients were not doctors and no impression was made that suggested any desire by the GP to maintain control over patients. Moreover, there was a sense of frustration that some patients would not engage in self-care8. Since it is unclear in this small study, it is a consideration for future research whether power dynamics influence GPs decision to provide self-care in practice.

Present findings showed that a patient’s characteristics, personality, beliefs and confidence in their own ability to self-care can influence whether the GP perceives self-care to be an appropriate option. Patient characteristics were closely identified with self-care and are considered to be situation and culture specific, encompassing the patient’s capacity to act and make choices. They are influenced by knowledge, skills, values, motivation, locus of control and efficacy, and focus on healthcare under individual control (as opposed to social policy or legislation)36,37. Furthermore, the person’s confidence (self-efficacy) and belief in being able to perform self-care behaviours has a greater influence than any physical limitations38. This study echoes the King’s Fund report40, reaffirming the need for healthcare professionals to provide patients with the foundations on which to build the confidence and appropriate skills to manage minor illnesses.

Patient characteristics have origins in health psychology and the term ‘locus of control’. This is a personality trait21 whereby people who can link their behaviour with an outcome hold an internal locus of control, as opposed to people (externals) who believe that things happen to them resulting from external forces39. One GP in this study mentioned not providing written information to patients with an internal locus of control, as they are likely to take more control in their health by searching for information, and therefore are less likely to rely on others in the process40. Several GPs’ perceived younger people as being less likely to self-care. A lack of interest in self-care was evident in persons under 35 years of age with low education and a lack of knowledge in minor illnesses12. Furthermore, research suggests that people’s preference to self-care has declined over time16,17. This can be assimilated to the perception of a younger generation’s reluctance to self-care for minor illness, in contrast to the perception by GPs that the elderly (through experience) are more likely to act independently and self-care more. However, the elderly have been shown to be more likely to consult a GP for minor illnesses, although the reasons for this are unstudied13. Nevertheless, GPs were aware of the dangers of elderly people self-caring with minor illness through misdiagnosis, potentially leading to inappropriate treatment, and resulting in delays in diagnosing/treatment of more serious illness25. Self-efficacy and locus of control are important factors to consider when exploring the patients’ ability to self-care, and notably influence GPs provision of self-care.

Results revealed some GPs’ preferences to offer either verbal advice, believing that patients pay more attention through dialogue, whilst others perceive written information to be more effective. Studies investigating the methods of self-care have produced mixed results and are mainly evaluative in terms of consultation rates and usefulness to patients in the wider healthcare setting41. Providing condition-specific patient information leaflets increases patient satisfaction42, can reduce attendance/health-seeking behaviour43-47, although other studies showed no effect on attendance41,48,49. This present study supports the findings from Plass et al50 which highlight the need for information to be tailored to the individual, and indicate a lack of appropriate written resources to support the diversity of cultures and languages. This might explain why people of non-Western origin are more inclined to seek healthcare services for minor illnesses, due to decreased patient understanding through language difficulty or education13. A systematic review presented cultural barriers that hinder ethnic minority patients from accessing diabetic services, including; adherence to cultural norms, religious beliefs, linguistic diversity, low health literacy levels, different beliefs about health and illness, belief in expert and professional support and low concordance with western professional advice51. It emphasises the complexity of culture which may hinder the practice of self-care for minor illness, regardless of whether self-care advice is provided or not.

In addition to culture and language, repetitive behaviour influences demand for consultations however, this creates opportunity for self-care as by promoting it every visit, the patient may be more inclined to self-care the next time17. Furthermore, this may stimulate expectation for patients to self-care and avoid the negative reactions reported by GPs. It is noteworthy, that GP participants did not always actively recommend that patients seek advice from pharmacists due to a perceived commercial conflict of interest of selling medicines. Banks’17 research found that consumers are also wary of asking pharmacists for advice, however notably they respond positively to recommendation. Therefore, without GP recommendations to discuss minor ailments with pharmacists, consumers may self-select medicines that may not be optimal for their needs, potentially leading to unnecessary consultations and prescriptions17. It is recommended therefore that education may enhance some GPs’ perceptions regarding the wider benefits of promoting pharmacists for advice.

GPs in this study intimated that prescriptions can potentially influence health-seeking behaviour for minor illnesses. This resonates with Plass et al50, as their research was conducted in the Netherlands at a time when insurance companies no longer reimbursed prescription costs for many minor illnesses treatments; this may have reduced consultations rather than the provision of self-care booklets. Although the majority of GPs stated they encourage patients to purchase OTC medicines rather than offering a prescription, this does not resonate with the findings from PAGB4 whereby 90% of all minor illness consultations resulted in a prescription. Although GPs held good intentions to promote OTC medications, there are others who would avoid the negative reaction from patients expecting a prescription and not receiving one, particularly if patients were provided with a prescription for the same minor illness in the past17.

Since this research was carried out, NHS England52 has provided guidance aimed at Clinical Commissioning Groups (CCGs), which lists conditions for which OTC items should not be routinely prescribed in primary care (appendix 3). The aim of this guidance is to support CCGs in reducing spending on conditions that are self-limiting, or which lend themselves to self-care, or items for which there is little clinical effectiveness52. However, there are certain exceptions whereby GPs can use their clinical judgement to continue to prescribe OTC medications, for example for patients with longer-term or more complex issues, or if the patient’s ability to self-manage is compromised. It is not known if this new guidance reduces health seeking behaviour and demand for appointments, or influences the provision of self-care information by GPs, as it was issued after the GP interviews and the main body of research took place.

Strengths and limitations
The use of in-depth interviews specifically to explore the influencing factors that promote self-care for minor illnesses by GPs is limited. The strengths of this study lie in the rich qualitative nature of the findings, and consistency in the views of the GPs being similarly reflected in previous studies. Limitations arise from thematic analysis which can result in the de-contextualisation of speaker’s words. Care was taken to closely analyse each interview transcript for accuracy in order to avoid unintended misinterpretation and misrepresentation. The interviews provided useful insight into GP perspectives, although it proved difficult for some GPs to recollect retrospectively their past experiences of providing self-care advice.

The interviewees were known to the researcher (collegial) which may have created insider researcher bias as interviewees may seek to manage the impression they make53. Familiarity with the GP participants may have risked coercion and/or the ability to give free consent as some GPs may have felt obliged to take part in the interviews for fear of offending the researcher. Conducting the interviews at a different GP surgery whereby participants were unknown/not colleagues to the researcher could have reduced the potential risk of coercion. To minimise the disruption to surgeries, the interviews were conducted in the GP’s lunch hour. Therefore, human factors could have influenced an individual’s response, particularly if the GP was interrupted mid-interview. Although participants were representative of GPs working at the practice, this was a small pre-selected convenience sample at one medical surgery and as such may not represent GP perspectives in different medical practices or geographical locations with different patient populations.

Implications for research/practice
This qualitative study explored the factors that influence GPs to provide self-care advice and adds to the limited body of knowledge in this area. GPs’ documentation on the provision of self-care was inconsistent which makes it difficult to evaluate whether providing advice had the desired effect. To compliment this study, further research could interview patients to explore whether they have received self-care information by GPs or not, their perspectives on receiving advice and whether they acted on it. Further research could include the influencing factors in the provision of self-care advice by other providers such as pharmacists and Nurse Practitioners. As alluded to in the discussion, the theory of power dynamics is an area that remains unexplored in relation to whether this affects the GPs provision of self-care advice; this could be an area for future research.

Self-care is important for managing minor illnesses however the guidance for providing consistent self-care information is limited. Present findings suggest that documentation when self-care was provided was inconsistent, unspecific and ambiguous. Scope exists for developing national policy/guidelines7,17 to provide clarity, and assist healthcare professionals when providing and documenting self-care advice. New NHS England guidance52 exists which lists conditions for which OTC items should not be routinely be prescribed in primary care. This guidance was not available at the time that this study was undertaken, therefore it is not known if it has affected GPs provision of self-care information. It would also be useful to find out if this new guidance has had any effect on health seeking behaviour for patients presenting with minor illnesses.

Correspondence to: Jennifer Bishop. Email: jenny.bishop@nhs.net

Funding: The researcher is employed part-time as an Advanced Nurse Practitioner at the participating medical practice; there was no funding provided for this study and interviews were conducted during the researchers’ own time.

Ethical issues: Ethical approval was subject to the University of West of England research governance processes: it was deemed low risk and approved.

Acknowledgements: I would like to thank all the GPs who contributed to this study by providing their valuable time for taking part in the interviews. Additional thanks to Amy, Carrie and Helen, for their support, input and help in making this study happen. A special thanks to my supervisor Pat Turton for her invaluable guidance and finally to my family for their understanding and encouragement throughout.

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appendix 1


International Self-care Foundation ‘The seven pillars of self-care’ illustrated schematically.
(Available from: http://isfglobal.org/practise-self-care/the-seven-pillars-of-self-care/)

Reproduced with kind permission of International Self-care Foundation

appendix 2

appendix 3

Keywords

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