title: Operationalising unscheduled care policy: a qualitative study of healthcare professionals' perspectives.
abstract: BACKGROUND
  UK health policy aims to reduce the use of unscheduled care, by increasing proactive and preventative management of patients with long-term conditions in primary care.
  
  
  OBJECTIVE
  The study explored healthcare professionals' understanding of why patients with long-term conditions use unscheduled care, and the healthcare professionals' understanding of their role in relation to reducing the use of unscheduled care.
  
  
  METHODS
  Qualitative study interviewing different types of healthcare professionals providing primary care or unscheduled care services in northwest England.
  
  
  METHODS
  Semi-structured interviews were conducted with 29 healthcare professionals (six GPs; five out-of-hours GPs; four emergency department doctors; two practice nurses; three specialist nurses; two district nurses; seven active case managers). Data were analysed using framework analysis.
  
  
  RESULTS
  Healthcare professionals viewed the use of unscheduled care as a necessary component of care for patients with long-term conditions. Those whose roles involved working to targets to reduce the use of unscheduled care described a tension between this and delivering optimum patient care. Three approaches to reducing unscheduled care were described: optimising the system; negotiating the system; and optimising the patient.
  
  
  CONCLUSIONS
  Current policy to reduce the use of unscheduled care does not take account of the perceptions of the healthcare professionals who are expected to implement them. Lipsky's theory of street-level bureaucrats provides a framework to understand how healthcare professionals respond to imposed policies. Healthcare professionals did not see the use of unscheduled care as a problem and there was limited commitment to the policy targets. Therefore, policy should aim for whole-system change rather than reliance on individual healthcare professionals to make changes in their practice.
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester 5th floor, Williamson Building, Oxford Road, Manchester, UK. jdrinkwater@doctors.org.uk
authors.forename: Jessica
authors.initials: J
authors.lastname: Drinkwater
authors.forename: Peter
authors.initials: P
authors.lastname: Salmon
authors.forename: Susanne
authors.initials: S
authors.lastname: Langer
authors.forename: Cheryl
authors.initials: C
authors.lastname: Hunter
authors.forename: Alexandra
authors.initials: A
authors.lastname: Stenhoff
authors.forename: Elspeth
authors.initials: E
authors.lastname: Guthrie
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
mesh_terms: D039602:After-Hours Care / Q000706:statistics & numerical data; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D002908:Chronic Disease / Q000628:therapy*; D032882:Comprehension; D004739:England; D064703:Family Nurse Practitioners; D058005:General Practitioners; D006291:Health Policy; D006801:Humans; D064691:Nurses, Community Health; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data*
references.citation: BMJ. 2005 Mar 19;330(7492):657-61
references.pmid: 15775000
references.citation: Soc Sci Med. 2008 Feb;66(3):765-75
references.pmid: 18006131
references.citation: J Health Polit Policy Law. 1998 Oct;23(5):795-832
references.pmid: 9803363
references.citation: Implement Sci. 2012 Jan 26;7:7
references.pmid: 22280501
references.citation: Br J Psychol. 1992 Feb;83 ( Pt 1):97-111
references.pmid: 1559146
references.citation: BMC Health Serv Res. 2007 Apr 27;7:61
references.pmid: 17466063
references.citation: Sociol Health Illn. 2004 Nov;26(7):951-75
references.pmid: 15610474
references.citation: Int J Nurs Stud. 2006 Sep;43(7):803-18
references.pmid: 16343500
references.citation: Med Care. 1999 Jan;37(1):5-14
references.pmid: 10413387
references.citation: Health Soc Care Community. 2013 Jul;21(4):339-51
references.pmid: 23009718
references.citation: BMJ. 2001 Oct 27;323(7319):962-6
references.pmid: 11679384
references.citation: J Adv Nurs. 2008 Apr;62(2):191-9
references.pmid: 18394031