You are here

  • Home
  • Archive
  • Volume 5, Issue 10
  • Patients’ perspectives on the medical primary–secondary care interface: systematic review and synthesis of qualitative research

Article Text

Article menu

This article has a correction. Please see:

XML
Qualitative research
Research
Patients’ perspectives on the medical primary–secondary care interface: systematic review and synthesis of qualitative research
  1. Rod Sampson1,
  2. Jamie Cooper2,
  3. Rosaline Barbour3,
  4. Rob Polson4,
  5. Philip Wilson5
  1. 1Cairn Medical Practice, Inverness, UK
  2. 2Aberdeen Royal Infirmary, Aberdeen, UK
  3. 3The Open University, Milton Keynes, UK
  4. 4Highland Health Sciences Library, Centre for Health Science, Inverness, UK
  5. 5Centre for Rural Health, University of Aberdeen, The Centre for Health Science, Inverness, UK
  1. Correspondence to Dr Rod Sampson; rod.sampson{at}nhs.net

Abstract

Objectives To synthesise the published literature on the patient experience of the medical primary–secondary care interface and to determine priorities for future work in this field aimed at improving clinical outcomes.

Design Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore patients’ perspectives of the medical primary–secondary care interface.

Setting International primary–secondary care interface.

Data sources EMBASE, MEDLINE, CINAHL Plus with Full text, PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection, Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index, and grey literature.

Eligibility criteria for selecting studies Studies were eligible for inclusion if they were full research papers employing qualitative methodology to explore patients’ perspectives of the medical primary–secondary care interface.

Review methods The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data.

Results The search identified 690 articles, of which 39 were selected for full-text review. 20 articles were included in the systematic review that encompassed a total of 689 patients from 10 countries. 4 important areas specific to the primary–secondary care interface from the patients’ perspective emerged: barriers to care, communication, coordination, and ‘relationships and personal value’.

Conclusions and implications of key findings Patients should be the focus of any transfer of care between primary and secondary systems. From their perspective, areas for improvement may be classified into four domains that should usefully guide future work aimed at improving quality at this important interface.

Trial registration number PROSPERO CRD42014009486.

  • PRIMARY CARE
  • QUALITATIVE RESEARCH

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 and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2015-008708

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Strengths and limitations of this study

    • This review employed rigorous and established methodology specific to qualitative studies throughout.

    • The quality of the included studies was assessed using a published framework (Critical Appraisal Skills Programme, CASP) and found to be uniformly high.

    • The independent analysis of full articles by two researchers generated themes, concordant between reviewers, in a transparent and reproducible manner and was considered helpful in maintaining a coding balance.

    • Given reciprocal translational analysis provides summaries in terms that may have already been used in the original literature, there is acknowledgement that the synthesis will tend towards the privileging of a priori over in vivo codes.

    • Patient preferences and experiences were synthesised from varying primary–secondary care interfaces in differing healthcare systems serving different populations, but are gleaned only from the published literature. Study findings may therefore not be generalisable to all situations.

    Introduction

    In numerous countries, primary care is the usual first point of professional contact for patients with a medical complaint. Many conditions are managed in primary care though some require more specialised medical expertise or treatment, necessitating access across the primary–secondary care interface to specialist attention, usually in hospitals as inpatients or outpatients.1 ,2 For patients who frequently transit the primary–secondary care interface, such as those with chronic conditions, coordination between the different disciplines is essential for the delivery of quality care.3 Since primary and secondary care clinicians often have different perspectives and can act in separate ‘professional tribes’, it is important that any inconsistencies across the primary–secondary care interface do not impact on the effectiveness and safety of patient transitions.4

    Although manifestations of the primary–secondary care interface across the world are diverse and the disciplines involved differ, similarities can be identified in most healthcare systems.5–7 In countries where general practice (or family medicine) is well developed, there are many similarities in the functions and characteristics of the primary–secondary care interface-based system, with general practitioners (GPs (or primary care physicians—PCPs)) usually acting as ‘gatekeepers’ to secondary care.2 ,5 In many nations, primary care is largely delivered by non-medically qualified practitioners, with less formal access to secondary care, and in others there is direct access to primary medical care provided by specialists, such as paediatricians, gynaecologists, specialists in internal medicine and cardiologists.2 ,5 ,8–11

    In countries with ‘gatekeeping’ primary care systems, there has been increased focus on the interface between primary and secondary care,12–17 highlighting the importance of better relationships between hospital and community, and between specialist and PCP, for the benefit of patient care.2

    Qualitative studies describing experience at the interface have highlighted the importance of good access to patient-centred care (ie, that which is respectful of and responsive to individual patient preferences, needs and values),18 ,19 but the amount of patient-focused work is limited.

    Aims

    Using a metaethnographic approach (a method for synthesising qualitative research studies) described by Noblit and Hare,20 this study aimed to identify what patients perceive as important markers of care quality at the primary–secondary care interface. Such an approach may generate greater understanding than a single empirical study and may be helpful in determining the direction of future work to improve clinical outcomes.21 ,22

    Methods

    Study registration

    The study was registered with the PROSPERO database, registration number CRD42014009486.

    The seven-step model of metaethnography described by Noblit and Hare20 was used. The first step involved a clear statement of the specific research question (What do patients perceive as important markers of care quality around the primary–secondary care interface?) and the contribution it will make to the field (to generate new insights, achieve greater understanding of the issues facing patients at the primary–secondary care interface than with a single empirical study, and determining targets for future research with the aim of improving patient outcomes). In step 2, a search strategy was devised to retrieve articles related to this aim. The search was focused to locate primary studies that met the following criteria.

    Eligibility criteria for study inclusion

    Studies were eligible for inclusion if they met all of the following criteria:

    • Employed qualitative methodology (focus groups or interviews);

    • Explored patients’ perspectives;

    • Targeted the medical primary–secondary care interface (ie, at the interface between PCP and secondary care hospital specialist);

    • Full research papers (ie, not an editorial, conference poster or abstract).

    Study exclusion criteria

    Studies were excluded if any of the following were present:

    • Non-qualitative methodology;

    • Did not explore patients’ perspectives;

    • Did not focus on the medical primary–secondary care interface (eg, studies focusing on the interface between social care and tertiary care would not be included);23–27

    • Not full research papers (ie, an editorial, conference poster or abstract).

    Information sources and search strategy

    Electronic databases were searched using database-specific terms and validated methods for retrieving qualitative studies (EMBASE (OVID 1974 to 30 July 2014), MEDLINE (OVID MEDLINE 1946 to 30 July 2014 with daily update), CINAHL Plus with Full text (EBSCO host accessed 30 July 2014), PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection (EBSCO host, last accessed 30 July 2014), Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index (database inception to 30 July 2014), and grey literature sources ((Open SIGLE (opensigle.inist.fr), last accessed 7 August 2014), (Health Management Information Consortium 1979 to May 2014 incorporating Kings Fund Information and Library service), (National Technical Information Service http://www.ntis.gov/, last accessed 7 August 2014) and (PsycEXTRA http://www.apa.org/psycextra/, last accessed 7 August 2014)) to identify literature using qualitative methods (focus groups or interviews) exploring patients’ perspectives of the primary–secondary care interface.23–27 No language or date of publication limits was applied to the search. Refer online supplementary appendix 1 ‘Search terms’ for specific detail of search used for each database. Authors of included studies were contacted to determine any key papers in the field of interest not identified by our own search strategy.

    Study selection

    One author (RS) examined titles and abstracts of all retrieved citations for eligibility according to the above criteria. The full-text articles of any abstracts classified as definitely or potentially suitable for inclusion were retrieved and analysed independently by two authors (RS and JC) against predefined inclusion and exclusion criteria with differences resolved by consensus.28 See online supplementary appendix 2 ‘Excluded studies’ for details of and reasons for study exclusion. Reference lists of all included studies were scrutinised for eligibility according to inclusion/exclusion criteria. Main authors of all included papers were contacted to explore the potential for any studies considered important to them that may have been missed in our search strategy.

    No quality filters were applied prior to inclusion of studies in the systematic review. However, the Critical Appraisal Skills Programme (CASP) tool for assessing qualitative research29 was applied postinclusion giving insights into the methods used for data collection and analysis (see online supplementary appendix 3 CASP review).

    Data extraction

    Step 3 of the metaethnographic synthesis involved reading the studies. Two authors (RS and JC) read and re-read the included studies, and independently listed the main themes from each article including both first-order (views of the participants) and second-order interpretations (views of authors). Where patients were interviewed with another healthcare professional, the analysis was restricted to the views of the patient where possible. Data were abstracted into standard fields, such as study aims, design, methods, setting and participants (see online supplementary appendix 4 ‘Data extraction template’),30 and entered into QSR International's NVivo V.10 software to assist qualitative analysis and synthesis.31

    Data synthesis

    In step 4, two of the authors (RS and JC) determined how the studies were related to each other by comparing individual study findings, and derived key concepts that reflected the main findings of all included studies. Subsequently (step 5; studies were translated into each other) each study was re-examined and assessed for its relevance to these key concepts. In the same way that primary study moves from descriptive to explanatory analysis, these translations were then synthesised (step 6) to develop third-order interpretations (higher levels of abstraction) to represent the overarching perspective of patients at the primary–secondary care interface. Members of the research team (RS/RB/PW) developed this third-order interpretation or ‘line of argument’ synthesis by listing the translated themes and subthemes (derived from first-order and second-order constructs reported in the primary studies), then review and discussion.

    The final step involved expressing the results of the synthesis using tables, figures and text in accordance with the ‘Enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement (see online supplementary appendix 5 ‘ENTREQ statement’).32

    Findings

    The electronic database search returned 690 citations, leaving 654 after removal of duplicates (see figure 1).

    Figure 1
    Figure 1

    Flow diagram of search.

    A further 618 articles were excluded after scrutiny of the title or abstract for using non-qualitative methodology (n=226), involving participants other than patients (n=195) or because they did not concern the experience of patients at the medical primary–secondary care interface (n=197).

    The full texts of all remaining 36 articles were retrieved and evaluated independently by two authors (RS/JC) against predefined criteria, leading to the inclusion of 20 papers (table 1). See online supplementary appendix 2 ‘Excluded Studies’ for details of, and reasons for, study exclusion.

    View this table:
    Table 1

    Characteristics of included studies

    Included studies originated from 10 countries and comprised a total of 689 patients (range 7–53 per study). Two studies used focus groups alone, 10 utilised solely individual patient interviews and 8 used both methods. The overall quality of the 20 included studies was high, with all articles meeting the majority of CASP criteria. One common weakness was around whether ethical issues had been taken into consideration (not clear in 5 of the 20 studies).34 ,37–39 ,47 The other common limitation was a lack of evidence demonstrating that the relationship between researcher and participants had been adequately considered; particularly whether the researcher(s) had critically examined their own role and potential for bias in formulation of topic guides, data collection, recruitment, study location, and whether they considered the implications of any changes in the research design (not reported in 17 of the 20 studies).35 ,37 ,38 ,40–42 ,44–50

    Translation of included studies

    Four key concepts that reflected the principal findings of all included studies were determined: barriers to care, communication, coordination, and relationships and personal value (table 2). Within each key concept, subthemes arose that are highlighted in bold.

    View this table:
    Table 2

    Translations between studies using first-order and second-order interpretations and their relation to key concepts

    Barriers to care

    There was a strong patient perception that lack of PCP knowledge could be an obstacle to the delivery of good clinical care; “If it's of a serious nature, I certainly wouldn't take the GP's word for it.”33 ,46–48 Conversely for some patients, this apparent knowledge deficiency was not a practical problem, as their PCP referred them on.33

    Some patients described the PCP acting as a barrier (the one who controls your entry into the system) they had to be overcome; “I was lucky, I didn't have to go to my GP because I collapsed in church.”34 ,35 ,46

    Access to the PCP was also perceived as an impediment; “you can be on the phone for hours trying to ring a doctor and you don't get anywhere. So I ring now for the paramedics.”35 ,36

    Further system problems were identified, such as perceived delays to specialist clinic appointments, postponements and cancellations. When at specialist clinics, patients described long waiting times, frequent consultation interruptions and a lack of time with clinicians.38–40 ,46 Patients spoke of being disempowered by system complexity,48 bureaucracy resulting in disjointed care (“There is a distance between the hospital and primary care. Each part protects his own territory”4) and personal stress.33

    Some patients reported that scheduled specialist follow-up was often unnecessary when they were well and described frustration at having to organise their lives around superfluous appointments.43

    Communication

    There were conflicting patient views of the effectiveness of communication across the interface. Some informants were satisfied, while others cited that inadequate communication between specialist and PCP could lead to provision of contradictory information by healthcare professionals, causing patient confusion.33 ,35 ,37 ,38 ,45 ,47 Use of informal routes of communication was mentioned as effective means of overcoming fragmentation in care.33

    Patients believe good communication with their doctor requires time; established trust, understandable information and good clinician interpersonal skills.18 ,35 ,37 ,39 ,40 ,45 ,46 ,48 Conversely, patient stress, inadequate information or a sense of not being listened to increased the perception of poor communication.37 ,38 ,40 ,44 ,47

    Certain patients responded to poor communication by becoming more proactive (eg, involving family members to act on their behalf, preparing lists of questions or quarrelling with clinical staff), while others became more anxious and uncertain.18 ,40 However, patients did not lay all responsibility for poor communication on healthcare professionals.38 Some perceived that their own lack of personal knowledge, lower comparative social status (eg, when attending a hospital specialist) or physical condition at time of consultation inhibited their ability to communicate with clinicians.18 ,37 ,38 ,47

    Problems with the transfer of information at the interface were considered a significant cause of three major concerns:

    1. Delays in care delivery: “considerable numbers of patients were dissatisfied with the length of time it took for the GP to be given word from the specialist”;38

    2. Frustration: “Separate clinics don't talk to each other or ring each other. I find the whole thing incredible the length of time it takes; it's just been horrendous, waiting weeks to see a consultant to be told ‘I don't know why you've been referred to me’…it can make you feel very insignificant”;18

    3. Inaccuracy, for example, incomplete hospital discharge information. In addition, lost referrals, professional schedule inflexibility, poorly communicated processes and resourcing issues highlighted complex difficulties.18 ,37 ,40 ,45 ,47 ,48

    Coordination

    Some patients preferred their PCP to coordinate care since they could see the ‘whole picture’33 ,35 ,37 ,39 ,45 and others described increased confidence about discharge from hospital when they believed their PCP managed the ‘gatekeeping’ role well and would be willing to refer or re-refer when necessary; “I’ve every faith in him…Any problems I’ve got I just pick up the phone. He’s a very good doctor. He gets down to it you know and if he’s not sure he says ‘Right, hospital!’”38

    Where formal care coordination roles were not clear, patients and family members often assumed this role in either a proactive or passive fashion.33 Proactivity was associated with provision of medication lists, a felt need to be assertive, initiation of PCP follow-up postdischarge and intentional modification of personal behaviour and clinical information disclosure to facilitate progression through the system; “I have to ‘play act’ when I see a GP. So I have to pretend that I am really ill and about to die before anything actually happens…I don't have a lot of faith in them.”37 ,40 ,44 ,46

    Patients appreciated being involved in clinical decisions46 ,47 and regularly felt they took a level of responsibility for coordination of their own care,33 ,47 ,48 even when things went wrong.41

    Coordination of patient care could be influenced by the role of their family or carer; “I wasn't sure I was going to agree to the hospital tests. It was the family that changed my mind,”35 ,48 and the level of information provided; “lack of information perpetuated patients’ feelings of an imbalance in status and power, and reduced their sense of being involved in their own care.”18 ,37 ,45 ,48

    Specialist nurses and those with specific care-coordinator roles were valued by patients in terms of access, liaison with specialist and PCP, thoroughness, and acting as a point of continuity within the hospital system.33 ,36 ,37 ,43 ,46 ,48

    Relationships and personal value

    Patients appreciated sympathetic ongoing relationships with their PCP; “He tries to help me, he is a really understanding doctor. He understands how I feel. I can really talk to him. He knows how I feel. I tell him where I am having the pain. I relate to him.”38 ,45 ,46 Good relationships with PCPs based on trust and understanding increased patient confidence to progress through the system18 ,45 and was thought central to help seeking. In particular, continuity of PCP was considered essential to build relationships in which patients felt safe to disclose concerns.48 Conversely, patients were less confident when the relationship with their PCP was poor or they were unable to see their usual PCP.18 Informal patient relationships with clinicians were sometimes used to facilitate progress through the system; “A patient with cancer must have connections, otherwise he gets lost in fairyland: go there, come back, wait, and so on.”33

    Patients’ personal perceptions of hospital care were related to the quality and consistency of their relationships with secondary healthcare professionals.39 ,43 Patients can sense they are not valued with predictable consequences; “I think you feel a bit like an accessory, you've got this great big medical system and you're not really part of it, the system rolls on whether you're there or not…as a patient I thought the system was there because of you, not you there because of the system. It's this great big wheel of medicine going round and round and you're an insignificant speck.”18 Attitudes of staff in practices and outpatient clinics can make patients feel ‘in the way’ and powerless to challenge failures in the system.18

    Patients also noticed tensions in the relationships between primary and secondary care, some expressing the view that PCPs and hospital doctors were not working together; “Is there maybe problems that the doctors are frightened to refer people to the hospitals-you know, they are the small fry and the hospital the big fry?”4 ,34 ,44

    Third-order interpretations and ‘the line of argument’

    Barriers to care

    Many patients perceived low levels of PCP knowledge as being a barrier. Access to the PCP was highlighted as a difficulty. Once in the system, clinician and staff attitudes were described as obstacles. Patients identified organisational and system problems as hindering progress.

    Communication

    Clinicians on both sides of the interface require good interpersonal skills and a patient-centred approach in order to communicate effectively. The effect of poor communication with patients (patient uncertainty, anxiety, unwillingness to communicate and the potential for quarrelling with clinicians) should not be underestimated.

    Coordination

    Some patients feel able to take on an active coordinating role in order to progress within the primary–secondary care interface. Patients value those healthcare workers with formal care coordinator roles (eg, specialist nurses).

    Relationships and personal value

    Good relationships with clinicians and staff, described as sympathetic, understanding and trusting promote patients’ sense of being valued and influenced disclosure of concerns, help seeking, compliance and confidence about referral and progress in the system. Patients sometimes used informal relationships with clinicians in order to advance through the system.

    Discussion

    This systematic review, to our knowledge the first attempt to synthesise the qualitative literature exploring the patient experience at the medical primary–secondary care interface, has led to a broader description and fuller understanding of the range of challenges that exist at this critical point in care delivery.

    Patients encounter multifaceted dynamics at the interface including barriers to care, communication, coordination of care issues and the impact of relationships and personal value.

    Comparison with other research

    Barriers to care

    Patients in several studies perceived low levels of PCP knowledge as a barrier to care, one specific example being the patient experiencing a delayed diagnosis of lung cancer which they specifically related to a lack of PCP knowledge.48 They contrasted the knowledge of the PCP and specialist, seeing the consultant as the ‘expert able to delve deeper’, in contrast to the PCP; “You need specialist input for some things, I don’t think that GPs have enough knowledge.”47 This subtle negative view of PCP knowledge base perhaps belies a lack of understanding of differing roles of PCPs and specialists in a ‘gate-keeping’ interface context. There may be potential for further clarification of this phenomenon, perhaps including a triangulated approach involving patient and peer assessment of PCP knowledge. Clinicians have a professional responsibility to maintain up to date knowledge and skills throughout their working career, and to regularly take part in educational activities that maintain and further develop competence and performance.51

    Systems need to be improved, so patients (and their information) can travel seamlessly across the interface between primary and secondary care. Medical notes should be complete, accurate and accessible to all relevant care providers.52 However, ‘information shared between GPs and hospitals when a patient moves between services is often patchy, incomplete and not shared quickly enough’.53 PCPs frequently receive hospital discharge summaries with deficient or inaccurate medicines information and delay in transmission of such information from secondary to primary may adversely affect patients.53–56 For example, in one study, PCPs felt it may have been important to carry out a follow-up home visit had they known that the patient had been discharged from hospital.56 The quality of patient information provided by PCPs to hospitals can also be substandard with regard to previous drug reactions, comorbidities and allergies.53 There certainly remains room for improvement54 ,57–69 and a need to develop and evaluate interventions to develop the content and speed of information sharing between primary and secondary care.70

    Communication

    The effect of poor communication skills on patients on both sides of the interface should not be underestimated: poor communication is an increasingly frequent reason for complaint71 when patients feel ‘disempowered and disengaged’ and patronised by clinicians.72 Inadequate time spent by clinicians with patients is associated with increased likelihood of malpractice litigation, largely due to poor communication.73 ,74 Cultural factors and educational background may influence clinician communication abilities.75 The question of how factors such as age and communication skills training impact on the doctor–patient relationship is interesting, and may merit further research.

    Coordination

    Patients vary in their ability to take on an active coordinating role of their progress within the primary–secondary care interface and value professionals adopting formal roles in this sphere. Though there has been some confusion about terminology,76 ,77 the clinical nurse specialist (CNS) is generally in a unique position with access to both PCP and specialist, as well as being available to the patient.78 ,79 This role is probably most developed and researched in patients with cancer where the CNS can improve quality of care, positively impact management, and improve understanding of treatment options and prognosis.80 Such roles may offer good value for money, reducing emergency admissions, length of hospital stay, follow-up appointments and providing support to enable end of life care in a place of the patient's choice.81 ,82 However, further research may be needed before firm recommendations can be made on the widespread value of CNSs in other chronic diseases.83

    Relationships and personal value

    Good relationships with clinicians were important to patients, influencing disclosure of concerns, help seeking, compliance, and overall confidence about referral and progress in the system.

    Some patients reported tensions between primary and secondary care, expressing the view that PCPs and hospital doctors were not working together.4 ,34 ,44 The influences on this relationship are complex and include political restructuring, patient demands and advances in medical knowledge.84 Professional ‘tribalism’, acknowledged on both sides, has the potential to undermine the effectiveness and safety of patient transitions,4 though good evidence supports that professionalism and desire for best clinical care can overcome these obstacles84 and lead to positive patient outcomes across the interface.84–86

    Strengths and limitations

    This review employed rigorous and established methodology specific to qualitative studies throughout. The search strategy (see online supplementary appendix 1) validated combinations of qualitative search terms to optimise the list of citations returned,27–30 was extensive to ensure inclusion of relevant articles in the sociology or psychology literature,31 and broad in order to retrieve all articles with important information on the primary–secondary care interface, even if the stated focus was not from a patient perspective. Further, there was no language restriction, and translations of potentially relevant titles and articles were obtained. Given reciprocal translational analysis provides summaries in terms that may have already been used in the original literature, there is acknowledgement that the synthesis will tend towards the privileging of a priori over in vivo codes.20 Further, the quality of the included studies was assessed using a published framework (CASP) and found to be uniformly high.

    The independent analysis of full articles by two researchers generated themes, concordant between reviewers, in a transparent and reproducible manner and was considered helpful in maintaining a coding balance.

    Patient preferences and experiences were synthesised from varying primary–secondary care interfaces in differing healthcare systems serving different populations,4 ,37 but are gleaned only from the published literature. Study findings may therefore not be generalisable to all situations.4 ,37 ,44 However, the countries represented in the synthesis do reflect a broad range of organisational and funding systems that, while not proportionally representative of the global picture, nonetheless provide findings relevant to individual national healthcare approaches.

    Several studies highlighted limitations in the research participant population (either in numbers or representativeness),33 which may also restrict transfer of findings to all patient groups and settings.40 ,41 ,44 ,50 Further, individual studies highlighted potential problems with the distinct participant characteristics of focus groups (eg, that views of quieter participants may have been lost), and the setting for group discussions.34 ,87 ,88 Other potential sources of bias were highlighted in individual studies including interviewer bias,49 recall bias41 and selection bias.40

    Though the results represent the real-life pragmatic challenges faced by patients at the primary–secondary care interface, the clinician perspective also requires consideration.

    Conclusions

    The key areas for patients in the primary–secondary care interface may be classified into four domains: barriers to care, communication, coordination, and relationships and personal value. These findings highlight the separate but inter-relating areas of patient experience that require intervention with the aim of improving patient care. There will not be a ‘one size fits all’ remedy but the domains that have emerged from this review give useful targets to guide the development of interventions that will assist and improve the provision of care to patients across the primary–secondary care interface. Further research may focus on the clinician experience of the interface, and from their perspective how this impacts on patient care.

    References

    1. ↵
      1. Fry J
      . Considerations of the present state and future trends of primary, personal, family, and general medical care. Int J Health Serv 1972;2:159–324.
      OpenUrl
    2. ↵
      1. Saltman RB,
      2. Rico A,
      3. Boerma W
      , eds. Primary care in the driver's seat? Organisational reform in European primary care. Open University Press, 2006.
    3. ↵
      1. Haggerty JL,
      2. Reid RJ,
      3. Freeman GK, et al
      . Continuity of care: a multidisciplinary review. BMJ 2003;327:1219–21. doi:10.1136/bmj.327.7425.1219
      OpenUrlFREE Full Text
    4. ↵
      1. Hesselink G,
      2. Vernooij-Dassen M,
      3. Pijnenborg L, et al
      . Organizational culture: an important context for addressing and improving hospital to community patient discharge. Med Care 2013;51:90–8. doi:10.1097/MLR.0b013e31827632ec
      OpenUrlCrossRefPubMed
    5. ↵
      1. Grimshaw JM,
      2. Winkens RA,
      3. Shirran L, et al
      . Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2005;3:CD005471. doi:10.1002/14651858.CD005471
      OpenUrlPubMed
    6. ↵
      1. Boerma WGW
      . Profiles of general practice in Europe. An international study of variation in the tasks of general practitioners. NIVEL, 2003. http://www.nivel.nl/sites/default/files/bestanden/profiles-of-general-practice-in-europe.pdf (accessed 7 Aug 2014).
    7. ↵
      1. Thomas S
      . European primary care': a visionary report of the Dutch Health Council on primary health care in the European Union. Ned Tijdschr Geneeskd 2005;149:1086–8.
      OpenUrlPubMed
    8. ↵
      1. Casparie AF,
      2. Hermans HEG,
      3. Paelinck JHP
      , eds. Competitive health care in Europe: future prospects. Dartmouth Publishing Company, 1988.
    9. ↵
      1. Gervas J,
      2. Perez-Fernandez M,
      3. Starfield BH
      . Primary care, financing and gatekeeping in Western Europe. Fam Pract 1994;11:307–17. doi:10.1093/fampra/11.3.307
      OpenUrlAbstract/FREE Full Text
    10. ↵
      1. Marinker M,
      2. Wilkin D,
      3. Metcalfe DH
      . Referral to hospital: can we do better? BMJ 1988;297:461–4. doi:10.1136/bmj.297.6646.461
      OpenUrlFREE Full Text
    11. ↵
      1. Roland MO,
      2. Coulter A
      . Hospital referrals. Oxford University Press, 1992.
    12. ↵
      1. Van Weel C
      . Teamwork. Lancet 1994;344:1276–9. doi:10.1016/S0140-6736(94)90756-0
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Busby H,
      2. Elliott H,
      3. Popay J, et al
      . Public health and primary care: a necessary relationship. Health Soc Care Community 1999;7:239–41. doi:10.1046/j.1365-2524.1999.00182.x
      OpenUrlCrossRefPubMedWeb of Science
    14. ↵
      1. Temmink D,
      2. Francke AL,
      3. Hutten JB, et al
      . Innovations in the nursing care of the chronically ill: a literature review from an international perspective. J Adv Nurs 2000;31:1449–58. doi:10.1046/j.1365-2648.2000.01420.x
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      1. Iliffe S,
      2. Lenihan P,
      3. Wallace P, et al
      . Applying community-oriented primary care methods in British general practice: a case study. Br J Gen Pract 2002;52:646–51.
      OpenUrlAbstract/FREE Full Text
    16. ↵
      1. Brown L,
      2. Tucker C,
      3. Domokos T
      . Evaluating the impact of integrated health and social care teams on older people living in the community. Health Soc Care Community 2003;11:85–94. doi:10.1046/j.1365-2524.2003.00409.x
      OpenUrlCrossRefPubMed
    17. ↵
      1. Rummery K,
      2. Coleman A
      . Primary health and social care services in the UK: progress towards partnership? Soc Sci Med 2003;56:1773–82. doi:10.1016/S0277-9536(02)00173-9
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Preston C,
      2. Cheater F,
      3. Baker R, et al
      . Left in limbo: patients’ views on care across the primary/secondary interface. Qual Health Care 1999;8:16–21. doi:10.1136/qshc.8.1.16
      OpenUrlAbstract
    19. ↵
      1. Baker R,
      2. Preston C,
      3. Cheater F, et al
      . Measuring patients’ attitudes to care across the primary/secondary interface: the development of the patient career diary. Qual Health Care 1999;8:154–60. doi:10.1136/qshc.8.3.154
      OpenUrlAbstract
    20. ↵
      1. Noblit G,
      2. Hare R
      . Meta-ethnography: synthesizing qualitative studies. Sage, 1988.
    21. ↵
      1. Ring N,
      2. Jepson R,
      3. Ritchie K
      . Methods of synthesizing qualitative research studies for health technology assessment. Int J Technol Assess Health Care 2011;27:384–90. doi:10.1017/S0266462311000389
      OpenUrlCrossRefPubMed
    22. ↵
      1. Campbell R,
      2. Pound P,
      3. Morgan M, et al
      . Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research. Health Technol Assess 2011;15:1–164.
      OpenUrlCrossRefPubMed
    23. ↵
      1. Wong SS,
      2. Wilczynski NL,
      3. Haynes RB, et al
      . Developing optimal search strategies for detecting clinically relevant qualitative studies in MEDLINE. Stud Health Technol Inform 2004;107:311–16.
      OpenUrlPubMed
    24. ↵
      1. Wilczynski NL,
      2. Marks S,
      3. Haynes RB
      . Search strategies for identifying qualitative studies in CINAHL. Qual Health Res 2007;17:705–10. doi:10.1177/1049732306294515
      OpenUrlAbstract/FREE Full Text
    25. ↵
      1. Walters LA,
      2. Wilczynski NL,
      3. Haynes RB, et al
      . Developing optimal search strategies for retrieving clinically relevant qualitative studies in EMBASE. Qual Health Res 2006;16:162–8. doi:10.1177/1049732305284027
      OpenUrlAbstract/FREE Full Text
    26. ↵
      1. McKibbon KA,
      2. Wilczynski NL,
      3. Haynes RB
      . Developing optimal search strategies for retrieving qualitative studies in PsycINFO. Eval Health Prof 2006;29:440–54. doi:10.1177/0163278706293400
      OpenUrlAbstract/FREE Full Text
    27. ↵
      Grey literature databases (accessed 7 Aug 2014) searched included; OpenSIGLE (http://opensigle.inist.fr), The Healthcare Management Information Consortium database (http://www.ovid.com/site/catalog/DataBase/99.jsp?top=2&mid=3&bottom=7&subsection=10), The National Technical Information Service (NTIS) (http://www.ntis.gov/), and PsycEXTRA (http://www.apa.org/pubs/databases/psycextra/index.aspx).
    28. ↵
      1. Atkins S,
      2. Lewin S,
      3. Smith H, et al
      . Conducting a meta-ethnography of qualitative literature: lessons learnt. BMC Med Res Methodol 2008;8:21. doi:10.1186/1471-2288-8-21
      OpenUrlCrossRefPubMed
    29. ↵
      CASP Qualitative Appraisal Checklist. Critical Appraisal Skills Programme Internet. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf (accessed 7 Aug 2014).
    30. ↵
      Joanna Briggs Institute Reviewers’ Manual: 2014 edition: The Joanna Briggs Institute. http://joannabriggs.org/assets/docs/sumari/ReviewersManual-Methodology-JBI_Umbrella%20Reviews-2014.pdf (accessed 7 Aug 2014).
    31. ↵
      NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 10, 2014.
    32. ↵
      1. Tong A,
      2. Flemming K,
      3. McInnes E, et al
      . Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol 2012;12:181. doi:10.1186/1471-2288-12-181
      OpenUrlCrossRefPubMed
    33. ↵
      1. Admi H,
      2. Muller E,
      3. Ungar L, et al
      . Hospital-community interface: a qualitative study on patients with cancer and health care providers’ experiences. Eur J Oncol Nurs 2013;17:528–35. doi:10.1016/j.ejon.2013.02.005
      OpenUrlCrossRefPubMed
    34. ↵
      1. Bain NSC,
      2. Campbell NC
      . Treating patients with colorectal cancer in rural and urban areas: a qualitative study of the patients’ perspective. Fam Pract 2000;17:475–9. doi:10.1093/fampra/17.6.475
      OpenUrlAbstract/FREE Full Text
    35. ↵
      1. Bain N,
      2. Campbell N,
      3. Ritchie L, et al
      . Striking the right balance in colorectal cancer care: a qualitative study of rural and urban patients. Fam Pract 2002;19:369–74. doi:10.1093/fampra/19.4.369
      OpenUrlAbstract/FREE Full Text
    36. ↵
      1. Beech R,
      2. Henderson C,
      3. Ashby S, et al
      . Does integrated governance lead to integrated patient care? Findings from the innovation forum. Health Soc Care Comm 2013;21:598–605.
      OpenUrl
    37. ↵
      1. Berendsen AJ,
      2. de Jong GM,
      3. Meyboom-de Jong B, et al
      . Transition of care: experiences and preferences of patients across the primary/secondary interface–a qualitative study. BMC Health Serv Res 2009;91:62. doi:10.1186/1472-6963-9-62
      OpenUrl
    38. ↵
      1. Burkey Y
      . Patients’ views on their discharge from follow up in outpatient clinics: qualitative study. BMJ 1997;315:1138–41. doi:10.1136/bmj.315.7116.1138
      OpenUrlAbstract/FREE Full Text
    39. ↵
      1. Davies E
      . Using clinical audit, qualitative data from patients and feedback from general practitioners to decrease delay in the referral of suspected colorectal cancer. J Eval Clin Pract 2007;13:310–17. doi:10.1111/j.1365-2753.2006.00820.x
      OpenUrlPubMed
    40. ↵
      1. Flink M,
      2. Ohlen G,
      3. Hansagi H, et al
      . Beliefs and experiences can influence patient participation in handover between primary and secondary care—a qualitative study of patient perspectives. BMJ Qual Saf 2012;21(Suppl 1):i76–83. doi:10.1136/bmjqs-2012-001179
      OpenUrlAbstract/FREE Full Text
    41. ↵
      1. Göbel B,
      2. Zwart D,
      3. Hesselink G, et al
      . Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens. BMJ Qual Saf 2012;21:i106–13. doi:10.1136/bmjqs-2012-001192
      OpenUrlAbstract/FREE Full Text
    42. ↵
      1. Hesselink G,
      2. Flink M,
      3. Olsson M, et al
      . Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Qual Saf 2012;21(Suppl 1):i39–49. doi:10.1136/bmjqs-2012-001165
      OpenUrlAbstract/FREE Full Text
    43. ↵
      1. Kemp K,
      2. Griffiths J,
      3. Campbell S, et al
      . An exploration of the follow-up needs of patients with inflammatory bowel disease. J Crohns Colitis 2013;7:e386–95. doi:10.1016/j.crohns.2013.03.001
      OpenUrlAbstract/FREE Full Text
    44. ↵
      1. McHugh GA,
      2. Silman AJ,
      3. Luker KA
      . Quality of care people with osteoarthritis: a qualitative study. J Clin Nurs 2007;16:168–76. doi:10.1111/j.1365-2702.2007.01885.x
      OpenUrlCrossRefPubMed
    45. ↵
      1. Pascoe SW
      . Patients’ experiences of referral for colorectal cancer. BMC Fam Pract 2013;14:124. doi:10.1186/1471-2296-14-124
      OpenUrl
    46. ↵
      1. Pollard LC,
      2. Graves H,
      3. Scott DL, et al
      . Perceived barriers to integrated care in rheumatoid arthritis: views of recipients and providers of care in an inner-city setting. BMC Musculoskelet Disord 2011;12:19. doi:10.1186/1471-2474-12-19
      OpenUrlCrossRefPubMed
    47. ↵
      1. Somerset M,
      2. Faulkner A,
      3. Shaw A, et al
      . Obstacles on the path to a primary care led National Health Service: complexities of outpatient care. Soc Sci Med 1999;48:213–25. doi:10.1016/S0277-9536(98)00338-4
      OpenUrlPubMed
    48. ↵
      1. Walton L,
      2. McNeill R,
      3. Stevens W, et al
      . Patient perceptions of barriers to the early diagnosis of lung cancer and advice for health service improvement. Fam Pract 2013;30:436–44. doi:10.1093/fampra/cmt001
      OpenUrlAbstract/FREE Full Text
    49. ↵
      1. Wilkes S,
      2. Rubin G,
      3. Crosland A, et al
      . Patient and professional views of open access hysterosalpingography for the initial management of infertility in primary care. Br J Gen Pract 2009;59:336–42. doi:10.3399/bjgp09X420608
      OpenUrlAbstract/FREE Full Text
    50. ↵
      1. Wright CA,
      2. Osborn DPJ,
      3. Nazareth I, et al
      . Prevention of coronary heart disease in people with severe mental illnesses: a qualitative study of patient and professionals’ preferences for care. BMC Psychiatry 2006;4:6.
      OpenUrl
    51. ↵
      General Medical Council. Good medical practice. General Medical Council. http://www.gmc-uk.org/guidance/good_medical_practice.asp (accessed 26 Mar 2015)
    52. ↵
      Institute for Healthcare Improvement http://www.ihi.org/Pages/default.aspx (accessed 26 Mar 2015)
    53. ↵
      Care Quality Commission. Managing patients’ medicines after discharge from hospital. Are Quality Commission, 2009. http://webarchive.nationalarchives.gov.uk/20101201001009/http://www.cqc.org.uk/_db/_documents/Managing_patients_medicines_after_discharge_from_hospital.pdf (accessed 26 Mar 2015).
    54. ↵
      1. Long A,
      2. Atkins JB
      . Communication between general practitioners and consultants. BMJ 1974;4:456–9. doi:10.1136/bmj.4.5942.456
      OpenUrlAbstract/FREE Full Text
    55. ↵
      1. Walton J,
      2. McLachlan G
      . Doctor to doctor: writing and talking about patients; a collection of essays from a Nuffield working party on communication. Nuffield Provincial Hospitals Trust, 1984.
    56. ↵
      1. Harding J
      . Study of discharge communications from hospital doctors to an inner London general practice. J R Coll Gen Pract 1987;37:494–5.
      OpenUrlPubMedWeb of Science
    57. ↵
      Scottish Intercollegiate Guidelines Network. Report of a recommended referral document. Scottish Intercollegiate Guidelines Network, 1998. http://www.sign.ac.uk/guidelines/fulltext/31/section1.html#15 (accessed 26 Mar 2015)
    58. ↵
      1. Coulter A,
      2. Noone A,
      3. Goldacre M
      . General practitioners’ referrals to specialist outpatient clinics. BMJ 1989;299:304–8. doi:10.1136/bmj.299.6694.304
      OpenUrlAbstract/FREE Full Text
    59. ↵
      1. De Alarcon R,
      2. Hodson JM
      . Value of the general practitioner's letter. A further study in medical communication. BMJ 1964;2:435–8. doi:10.1136/bmj.2.5406.435
      OpenUrlFREE Full Text
    60. ↵
      1. Hodge JA,
      2. Jacob A,
      3. Ford MJ, et al
      . Medical clinic referral letters. Do they say what they mean? Do they mean what they say? Scott Med J 1992;37:179–80.
      OpenUrlAbstract/FREE Full Text
    61. ↵
      1. Hull FM,
      2. Westerman RF
      . Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam. BMJ 1986;293:311–14. doi:10.1136/bmj.293.6542.311
      OpenUrlAbstract/FREE Full Text
    62. ↵
      1. Jacobs LG,
      2. Pringle MA
      . Referral letters and replies from orthopaedic departments: opportunities missed. BMJ 1990;301:470–3. doi:10.1136/bmj.301.6750.470
      OpenUrlAbstract/FREE Full Text
    63. ↵
      1. Jenkins RM
      . Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner. Br J Gen Pract 1993;43:111–13.
      OpenUrlAbstract/FREE Full Text
    64. ↵
      1. Kentish R,
      2. Jenkins P,
      3. Lask B
      . Study of written communication between general practitioners and departments of child psychiatry. Br J Gen Pract 1987;37:162–3.
      OpenUrlAbstract/FREE Full Text
    65. ↵
      1. Newton J,
      2. Eccles M,
      3. Hutchinson A
      . Communication between general practitioners and consultants: what should their letters contain? BMJ 1992;304:821–4. doi:10.1136/bmj.304.6830.821
      OpenUrlAbstract/FREE Full Text
    66. ↵
      1. Newton J,
      2. Hutchinson A,
      3. Hayes V, et al
      . Do clinicians tell each other enough? An analysis of referral communications in two specialties. Fam Pract 1994;11:15–20. doi:10.1093/fampra/11.1.15
      OpenUrlAbstract/FREE Full Text
    67. ↵
      1. Pullen I,
      2. Yellowlees A
      . Is communication improving between general practitioners and psychiatrists? BMJ 1985;290:31–3. doi:10.1136/bmj.290.6461.31
      OpenUrlAbstract/FREE Full Text
    68. ↵
      1. Roland M,
      2. Porter RW,
      3. Matthews JG, et al
      . Improving care: a study of orthopaedic outpatient referrals. BMJ 1991;302:1124–8. doi:10.1136/bmj.302.6785.1124
      OpenUrlAbstract/FREE Full Text
    69. ↵
      1. Westerman RF,
      2. Hull FM,
      3. Bezemer PD, et al
      . A study of communication between general practitioners and specialists. Br J Gen Pract 1990;40:445–9.
      OpenUrlAbstract/FREE Full Text
    70. ↵
      1. Farquhar MC,
      2. Barclay SI,
      3. Earl H, et al
      . Barriers to effective communication across the primary/secondary interface: examples from the ovarian cancer patient journey (a qualitative study). Eur J Cancer Care 2005;14:359–66. doi:10.1111/j.1365-2354.2005.00596.x
      OpenUrlWeb of Science
    71. ↵
      General Medical Council. The state of medical education and practice in the UK. General Medical Council, 2012. http://www.gmc-uk.org/publications/somep2012.asp (accessed 26 Mar 2015)
    72. ↵
      Patients Association. Primary care: GPs and patients—partners in care? Patients Association, 2012. http://www.patients-association.com/default.aspx?tabid=80&Id=95 (accessed 26 Mar 2015)
    73. ↵
      1. Falker ES
      . The medical malpractice in obstetrics: a gestalt approach to reform. Cardozo Womens LJ 1997;4:1–32.
      OpenUrl
    74. ↵
      1. Roter D
      . The patient-physician relationship and its implications for malpractice litigation. J Health Care Law Policy 2006;9:304–14.
      OpenUrl
    75. ↵
      Oxtoby J Are GPS poor communicators BMJ Careers. 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20009743 (accessed 9 Jan 2015)
    76. ↵
      Department of Health. Cancer Reform Strategy—second annual report. 2009. Department of Health, 2009. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_109339.pdf (accessed 26 Mar 2015).
    77. ↵
      1. Corner J,
      2. Halliday D,
      3. Haviland J, et al
      . Exploring nursing outcomes for patients with advanced cancer following intervention by Macmillan specialist palliative care nurses. J Adv Nurs 2003;41:561–74. doi:10.1046/j.1365-2648.2003.02568.x
      OpenUrlCrossRefPubMedWeb of Science
    78. ↵
      1. Douglas H-R,
      2. Halliday D,
      3. Normand C, et al
      . Economic evaluation of specialist cancer and palliative nursing: Macmillan evaluation study findings. Int J Palliat Nurs 2003;9:429–35. doi:10.12968/ijpn.2003.9.10.19788
      OpenUrlPubMed
    79. ↵
      Royal College of Nursing. Maxi nurses: nurses working in advanced and extended roles promoting and developing patient-centred healthcare. Royal College of Nursing, 2005. http://www.rcn.org.uk/__data/assets/pdf_file/0004/78646/002511.pdf (accessed 26 Mar 2015).
    80. ↵
      Department of Health. Cancer Patient Experience Survey 2011/12: National Report. Department of Health, 2012. http://www.ncin.org.uk/view?rid=1713 (accessed 26 Mar 2015).
    81. ↵
      Macmillan Cancer Support. Cancer clinical nurse specialists: an evidence review. Macmillan Cancer Support, 2011.
    82. ↵
      National Cancer Action Team. Quality in nursing excellence in cancer care: the contribution of the clinical nurse specialist. National Cancer Action Team, 2010. http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/ExcellenceinCancerCaretheContributionoftheClinicalNurseSpecialist.pdf (accessed 26 Mar 2015).
    83. ↵
      1. De Broe S,
      2. Christopher F,
      3. Waugh N
      . The role of specialist nurses in multiple sclerosis: a rapid and systematic review. Health Technol Assess 2001;5:1–47.
      OpenUrlCrossRefPubMed
    84. ↵
      1. Marshall MN,
      2. Phillips DR
      . A qualitative study of the professional relationship between family physicians and hospital specialists. Prof Geogr 1999;51:274–82. doi:10.1111/0033-0124.00164
      OpenUrl
    85. ↵
      1. Horne R,
      2. Mailey E,
      3. Frost S, et al
      . Shared care: a qualitative study of GPs’ and hospital doctors’ views on prescribing specialist medicines. Br J Gen Pract 2001;51:187–93.
      OpenUrlAbstract/FREE Full Text
    86. ↵
      1. Brez S,
      2. Rowan M,
      3. Malcolm J, et al
      . Transition from specialist to primary diabetes care: a qualitative study of perspectives of primary care physicians. BMC Fam Pract 2009;10:39. doi:10.1186/1471-2296-10-39
      OpenUrlCrossRefPubMed
    87. ↵
      1. Michell L
      . Combining focus groups and interviews: telling how it is; telling how it feels. In: Barbour RS, Kitzinger J, eds. Developing focus group research: politics, theory and practice. Sage, 1999:36–46.
    88. ↵
      1. Green J,
      2. Hart L
      . The impact of context on data. In: Barbour RS, Kitzinger J, eds. Developing focus group research: politics, theory and practice. Sage, 1999:21–35.

    Supplementary materials

    Footnotes

    • Twitter Follow Rod Sampson at @SampsonRod

    • Contributors RS designed the study, undertook the systematic review, carried out the data extraction, analysis and interpretation, and wrote the manuscript. RB provided guidance on qualitative research methods and reviewed the manuscript. JC participated in the analysis and interpretation of results and reviewed the manuscript. PW participated in the design of the review, analysis and interpretation of results, and critical review of the manuscript. RP provided assistance in developing an appropriate search strategy and reviewed the manuscript. All authors had full access to all of the data (including tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. RS is the guarantor.

    • Funding NHS Highland Research, Development & Innovation Department, Aberdeen University, and Stirling University provided funds to meet publication costs.

    • Competing interests None declared.

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

    • Data sharing statement Additional data on the assessment of quality of included papers are available from rod.sampson@nhs.net.

    Linked Articles