Tim Norfolk and Prof Niro Siriwardena have recently published a discussion paper in Quality in Primary Care describing ‘A comprehensive model for diagnosing the causes of individual medical performance problems: skills, knowledge, internal, past and external factors (SKIPE)‘.

The SKIPE model, developed by Tim Norfolk, an occupational psychologist, through his work with underperforming doctors, sets out in logical relationship and progression the causal factors determining effective medical performance or underperformance. It highlights how the relationship between competence and performance is moderated by specific, discrete causal factors both within the individual and external to the individual.

This model builds on a previous paper describing a unifying theory of clinical practice, the RDM-p model, which captures the primary skill sets required for effective medical performance (relationship, diagnostics and management), and the professionalism that needs to underpin them. The SKIPE model is currently being used, in conjunction with the RDM-p model, for the in-depth assessment and management of doctors whose performance is a cause for concern.

A new interview study from members of the CaHRU team, ‘Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study‘ provides further insights into primary care management of insomnia. The study team interviewed 28 patients and 23 health professionals (GPs, nurse, mental health workers and community pharmacists) and analysed the transcripts of these discussions.

They found that practitioners focused on treating the cause of insomnia rather than the insomnia itself, used sleep hygiene (which patients often disregarded) rather than cognitive behavioural therapy for insomnia and were ambivalent towards hypnotic drugs. They often prescribed hypnotics in ‘collusion’ with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended by their doctors, for example together with over-the-counter medication.

Both practitioners and patients were sometimes but not always concerned about addiction which led practitioners to sometimes prescribe despite these concerns but at other times withdraw hypnotics abruptly. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care. The authors concluded that a better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training. These findings build on previous work as part of the REST project (www.restproject.org.uk) which also led to development of an e-learning programme on insomnia (http://elearning.restproject.org.uk/).

Left to right: Hanne Creupelandt, Sibyl Anthierens, Susan Chipchase and Coral Sirdifield

A new study has been published in BMC Family Practice on’General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis‘. The study was conducted by teams of researchers from the Universities of Lincoln (Coral Sirdifield, Susan Chipchase, Niro Siriwardena), Antwerp (Sibyl Anthierens) and Ghent (Hanne Creupelandt, Thierry Christiaens) who have been working on benzodiazepine and sleeping tablet prescribing by family doctors over the past decade.

The investigators systematically reviewed and synthesised the qualitative literature on benzodiazepine prescribing by family doctors. The analysis of eight studies from seven countries published between 1993 and 2010 showed that prescribing decisions for benzodiazepines were complex, uncomfortable, and demanding. There was variation between GPs and in individual GPs in the extent to which they were willing to prescribe benzodiazepines. GPs were ambivalent and inconsistent in attitudes towards benzodiazepines prescribing because of the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs’ attitudes to benzodiazepines, perceived lack of alternative treatment options and GPs’ perception of patient expectations and the doctor-patient relationship.

Model of factors influencing benzodiazepine prescribing

The model developed by the research team could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing. This could be brought about through various means including education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.