Table 5

Barriers to GP engagement with specialist secondary services in integration of palliative care

Author, dateOutcome measuresLength of follow-upResults
Narrative
Brazil et al, 200733 Structure of care
Processes of care
Outcomes of care
NA
  • Challenges:

  • ▸ Financial issues such as funding palliative care specialists

  • ▸ Shortage of trained staff

  • ▸ Insufficient training opportunities for primary care

  • ▸ Lack of infrastructure and technology

  • ▸ Difficulty providing care over large geographic area

Qualitative
Davison and Shelby-James, 201236 Camey's ladder of analytical abstraction was applied to the transcriptions.No follow-upThe purpose of the case conference was ambiguous with a lack of understanding or description. The person providing the purpose varied. Participant roles in the case conference were ambiguous. Description of roles varied depending on who was providing description.
Information was not provided by any service to any other service prior to the case conference, although this had been expected when necessary. Oral history brought to the conference filled gaps and informed decision making.
There is no standard membership to the case conference.
Mason et al, 201334 Ethnographic observations for 22 weeks. Interviews conducted 8–12 weeks intervals for 5–9 months or until death.
Interviews with professionals completed once.
Observations: at all sites there were problems with exchange of information between service providers when patients moved between services. Tensions arose between delivery of patient centred care and the need to promote efficiency. There was considerable variability in knowledge of palliative care.
Interviews:
patient identification must precede coordination of care. Advanced cancer patients were likely to be identified and receive good coordinated care, mismatch between policy and guidance around identifying patients for palliative care and the actual practice of identification
Palliative care was often thought of when no cure is possible and death is imminent by patients and carers.
Patients and families showed little understanding of benefits of palliative care.
GP was sometimes recognised as playing a key role. After discharge patients were disturbed by lack of follow-up from GP.
Mitchell et al, 200527 Disadvantages—workload pressure, teleconference format not ideal
Norman et al 32 No follow-up—one-off interviewsCancer care is organised in either a sequential, parallel or shared manner between FPs and cancer specialists. Cancer patients lose contact with FP because of relocation, distrust over delays in diagnosis, failure to perceive a need, poor communication between specialist and FP and lack of FP involvement in hospital.
Street and Blackford 200129 No follow-upIssues that impeded communication between palliative care nurses and GPs were networking, case management, multiple service providers, lack of standardised documents and tracking of clients, difficulties in providing relevant practical knowledge.
Tucker 201337 No follow-upVertical integration with secondary hospital care was common but considered competitive rather than collaborative.
Surveys
Brogaard et al, 201131 Identification of actual key worker and ideal key workerPatients, relatives, GPs and CNs most often saw themselves as the key worker.
When asked about the ideal key worker, most patients (29%, 95% CI 18% to 42%) and relatives (32%, 95% CI 22% to 45%) pointed to the GP. There was poor agreement regarding who is the key worker.
Goldschmidt et al, 200525 1 month after start of home careLack of benefits included home care team not helping when asked, wrong or no change in medical treatment and waiting too long. Confusion over who is in charge of what.
Dissatisfaction—organisational issues, communication problems and problems during home conference (eg, wrong focus, badly prepared)
Groot et al, 200735 Communication
Organisation
Knowledge and expertise
Integrated care
Time for relatives
No follow-upCommunication with relatives—over 50% experienced difficulties, more than 80% reported difficulties with bureaucratic procedures in organisations
Lack of GP expertise in home care technologies
Integrated care—GPs reported obtaining extra care for patient as the most problematic topic.
  • CN, community nurses; FP, family physician; GP, general practitioner; NA, not available.