title: Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice.
abstract: OBJECTIVE
  To examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland.
  
  
  METHODS
  Qualitative using semistructured interviews.
  
  
  METHODS
  Primary care in the Republic of Ireland.
  
  
  METHODS
  Purposive sample of 29 general practitioners (GPs) and two practice nurses.
  
  
  METHODS
  Data were analysed using a framework approach.
  
  
  RESULTS
  The main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level. The lack of targeted remuneration for diabetes management in the Irish health system created apathy in general practice and was perceived to be indicative of the lack of value placed on chronic disease management in the health system. There were 'pockets of interest' among GPs motivated by 'vocational' incentives such as a sense of professional duty; however, this was not sufficient to drive widespread improvement. The hospital service was seen as an essential support for primary care management, although some participants referred to emerging tension between settings. The lack of coordination at the primary-secondary interface resulted in avoidable duplication and an 'in the meantime' period of uncertainty around when patients would be called or recalled by specialist services. Facilitators included the availability of nursing support and serendipitous access to services. The lack of resources in the community was considered to be at odds with policy to shift routine management to general practice, which is fast reaching saturation.
  
  
  CONCLUSIONS
  At present, intrinsic motivation is driving the improvement of diabetes care in Ireland. This will not be sufficient to implement the proposed reform including a national model of integrated care. Policymakers need to assess and prepare for the disparate levels of interest and infrastructure in primary care in Ireland to support this change.
authors: Department of Epidemiology & Public Health, University College Cork, Cork, Ireland.
authors: Sheena
authors: S
authors: Mc Hugh
authors: Monica
authors: M
authors: O'Mullane
authors: Ivan J
authors: IJ
authors: Perry
authors: Colin
authors: C
authors: Bradley
keywords: DIABETES & ENDOCRINOLOGY; PRIMARY CARE
references: BMJ. 1995 Jul 1;311(6996):42-5
references: 7613329
references: Br Med J (Clin Res Ed). 1982 Sep 18;285(6344):787-9
references: 6811003
references: Qual Saf Health Care. 2005 Feb;14(1):4-5
references: 15691995
references: Int J Integr Care. 2001;1:e21
references: 16896400
references: Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78
references: 11816692
references: BMJ. 2012 Jul 13;345:e4451
references: 22797845
references: Diabet Med. 2002 Jul;19 Suppl 4:13-20
references: 12121332
references: BMJ. 2000 Jan 8;320(7227):114-6
references: 10625273
references: Soc Sci Med. 2002 Apr;54(8):1255-66
references: 11989961
references: BMC Health Serv Res. 2011 Dec 28;11:348
references: 22204759
references: Int J Qual Health Care. 2003 Apr;15(2):111-8
references: 12705704
references: Health Serv Res. 2007 Aug;42(4):1758-72
references: 17286625
references: Fam Pract. 2002 Aug;19(4):344-9
references: 12110552
references: BMJ. 2012 May 31;344:e3529
references: 22654064
references: BMJ Qual Saf. 2011 Jan;20(1):76-86
references: 21228079
references: BMJ. 1992 Jan 25;304(6821):235-9
references: 1739800
references: Qual Saf Health Care. 2002 Jun;11(2):148-52
references: 12448807
references: Cochrane Database Syst Rev. 2000;(3):CD002215
references: 10908531
references: Lancet. 2001 Aug 11;358(9280):483-8
references: 11513933
references: Eur J Gen Pract. 2008;14(3-4):117-22
references: 22548297
references: JAMA. 2003 Apr 16;289(15):1969-75
references: 12697800
references: Br J Gen Pract. 2001 May;51(466):356-60
references: 11360698
references: Prim Care Diabetes. 2009 Nov;3(4):225-31
references: 19837640
references: JAMA. 2002 Oct 9;288(14):1775-9
references: 12365965
references: Diabet Med. 2003 Oct;20(10):853-7
references: 14510868