What do consumers with chronic conditions expect from their interactions with general practitioners? A qualitative study of Australian consumer and provider perspectives

Abstract Background More than half of Australian adults manage one or more chronic conditions through ongoing interactions with general practitioners (GPs). Their experience of general practice interactions has important implications for their health outcomes and is thus important to explore in‐depth. Consumer expectations have emerged as a key consideration in this regard. How well they met in care settings can inform consumers' satisfaction and response to the care received. However, consumer expectations in Australian general practice are not well researched. Objective To identify key consumer expectations in clinical interactions in Australian general practice based on consumer and GP perspectives. Design Qualitative, phenomenological approach using thematic analysis of semi‐structured interviews. Setting and participants Thirty‐one participants: 18 patients with one or more chronic (persisting > 6 months) conditions, 10 GPs and 3 GP registrars in Sydney, Australia. Results Consumer expectations were strongly related to the context of their ongoing therapeutic relationship with a regular GP. Themes relating to some of the most commonly reported consumer expectations were as follows: (a) the importance of longevity and continuity; (b) having good rapport; (c) GP's respect for consumer opinions and expertise; (d) having effective communication; and (e) addressing mental health. Conclusion Australian GPs and consumers prioritize a positive, long‐term clinical relationship in which they respect one another and can communicate their expectations freely. This has implications for consumer satisfaction and in turn ensuring relational continuity, which is particularly relevant to the ongoing care and management of consumers with chronic conditions.


| INTRODUC TI ON
The burden of chronic conditions is a major problem in developed countries. Globally, close to three out of four older adults live with multiple chronic conditions. 1 In Australia, half of the population live with at least one chronic disease, accounting for disproportionate health and cost burden. 2 As in many other countries, much of the care and management of these individuals in Australia takes place in primary care settings, including general practice. 3 General practitioners (GPs) are among various health professionals who play a vital role in the care of patients at this level. GPs act as the gatekeeper, manager and coordinator of various health services for patients, in addition to directly providing care that includes prevention and early intervention. [4][5][6] They play a particularly important role in the care of individuals living with one or more chronic conditions, who require a multitude of services to manage their symptoms and illnesses. As such, these consumers tend to have regular and routine interactions with GPs, usually on a long-term basis, 7 and understanding their perception and experience of these interactions can provide a useful insight into the quality of care in general practice. The value of consumer-reported quality of care has been widely documented in literature: consumers who report high quality of care have been shown to have better rates of treatment adherence, 8,9 improved self-management skills, 10 greater motivation (or 'activation') to manage care 11 and a positive, ongoing relationship with their GP 12 -factors that are critical to good chronic disease management. Thus, understanding what influences their perception of quality can help inform the delivery of more appropriate and effective care to these consumers.
Consumer expectations of care have been shown to be an effective predictor of perceived care quality. [13][14][15] Juxtaposed against their actual experiences of care, these expectations -and whether or not they were met by the care provider -provide an indication of consumers' satisfaction with the care received. 14,16 This comparison forms the lens through which consumers perceive the quality of care and in turn can shape future expectations of care. 17 The definition of consumer expectations varies in literature but is often understood as how likely consumers believe that 'given events will occur during, or as an outcome of, health care'. 14,18 Consumer expectations have also been broadly conceptualized and expressed as beliefs, hopes, needs, wishes and desires about the health services they receive. 19,20 While expectations are partly about what consumers anticipate will happen ('What is the care I think I will be getting?'), they also include their projection of what could happen under ideal circumstances ('What is the care I think I could be getting?'). [14][15]21 Consumer expectations can also be normative, in that they represent the consumers' evaluations of what they ought to or should receive from health services. 15 Individuals managing chronic conditions usually have experience and knowledge of the health-care system that enables them to speak on these types of expectations informatively. The views of such consumers are thus valuable to capture from research and clinical practice standpoints.
Despite the importance of understanding consumer expectations, there is a paucity of research in this area with respect to clinical interactions in Australian general practice. This knowledge gap presents a missed opportunity to understand the quality of ongoing clinical interactions for those managing chronic conditions. Through consumer and GP perspectives, our qualitative study thus aimed to identify key consumer expectations in clinical interactions, based on the experience of people that are managing one or more chronic conditions in Australian general practice. This work builds on a previous study to understand patient experience of general practice, which identified accessibility barriers leading up to the consultation, including the affordability of care and availability of various modes of service delivery. 7

| ME THODS
A qualitative study was undertaken to capture and understand the breadth and depth of participant experiences. We conducted phenomenological research, which has been used in other studies to explore consumer expectations in health care. 19,22 This methodology is typically used to generate new knowledge about a phenomenon that is not well-known or researched, so that others may learn about its 'essential features'. 23 Consistent with this approach, this study aimed to describe the essence -or common themes -of participants' lived experiences of general practice interactions. 24,25 While we attempted to describe these experiences as closely to how they were reported by the participants, we concurrently acknowledged that 'there are no such things as uninterpreted phenomena'. 25 In other words, the descriptions of participant experiences, including the themes that were identified, inevitably represent our own interpretation of these experiences. This was the underlying epistemological assumption in this study.

| Sample and setting
Participants were recruited from three primary health networks (PHNs) in Sydney, Australia, including one rural area (Nepean Blue Mountains). A purposive sampling procedure was carried out to ensure that the cultural, linguistic, socio-economic and geographic diversity of the Australian population was represented. Participants recruited were people living with one or more chronic conditions Australia, chronic disease, clinical interaction, expectations, general practitioners, patient experience (persisting for more than 6 months) 26 and GPs, including registrars. Consumers were initially recruited by an expression of interest through Health Consumers New South Wales. The inclusion criteria for consumer participants are described in Table 1. GPs were first recruited from practices known to the researchers and from directories provided by the PHNs. An invitation letter was sent by fax or email. Snowball sampling through relevant contacts known to participants completed the recruitment of all participants until thematic saturation was reached.

| Data collection
Qualitative, semi-structured interviews were conducted between Interviews were held in person for GPs who requested this interview method for convenience and took place in their office. For consumers, interviews took place by telephone to allow participants to speak freely without social pressure (eg in the GP clinic) and due to distance. Interviews lasted between 15 and 60 minutes (mean of 26 minutes), were recorded and transcribed verbatim. Field notes were made by the interviewer during data collection. Participants were also invited to provide any additional responses or clarifications post-interview by email or telephone.

| Analysis
The data were coded and thematically analysed using a process described by Braun and Clarke. 27 After the initial review and familiarization of the transcripts, the data were coded inductively, a process by which knowledge is derived from the data without using pre-conceived conceptualizations or existing theories. Relevant and similar codes were then collated into themes, which were further refined using an iterative process in which themes and subthemes were added, removed, grouped, moved, relabelled, redefined and confirmed. Data analysis was done collaboratively by all researchers (HJS, SD, JFL, MH) and was guided by ongoing discussion of themes and iterative revisions of coding. Analytical memos were developed after coding and analysing each transcript, which were used to guide the interpretation of findings. NVivo 11 qualitative analysis software (QSR International) was used for coding, analysing and managing all data.

| Ethics
This study was approved by the Human Research Ethics Committee at the University of New South Wales (HC16529). All participants were provided with a participant information sheet and provided their written informed consent to participate.

| Participants
A total of 31 participants were included in the study, including 19 consumers and 13 GPs (including three registrars).
Information about participant characteristics was also collected at the time of the interview and is detailed in Tables 2 and

Inclusion criteria for consumers
Living with one or more chronic conditions (symptoms lasting ≥ 6 mo): • With or without an official medical diagnosis • Can be a rare, unknown or not well-understood condition (self-reported) Currently managing the condition(s) with a regular GP in general practice in one of three participating Sydney PHNs (Central and Eastern Sydney, South Western Sydney, Nepean Blue Mountains) At least 18 y of age Does not have a cognitive, psychological or other impairment that would prevent independent participation in the study. 3. Consumers reported seeing the same GP for a median of 8 years.

TA B L E 2 Characteristics of consumer participants
Four participants reported having a rare or poorly understood medical condition. More than half were recruited from patient advocacy or consumer representative organizations. Seven consumers also had a background as a health-care professional or in a health care-related area (eg medical research, health-care administration).
Registered GPs (non-registrars) in this study had been practising in general practice for a median of 26 years, and registrars had been practising for a median of 1.5 years.

| Consumer expectations of general practice interactions
Consumer expectations were relayed through past and current ex-

Clinical benefits of informational continuity in chronic care
Participants reflected on the importance of having a regular, long- GPs also perceived that the continuity in the relationship led to better health management and outcomes in consumers, especially for those with a complex set of health issues. Establishing this continuity with consumers was a priority for GPs, who stressed the importance of ensuring that they return routinely for visits: GP participants believed that having a positive relationship with consumers was crucial to their own work, with one participant characterizing general practice as 'a relationship-driven profession'.
They perceived that this also enabled a greater sense of trust from consumers that made them more willing to agree with the GP's recommendations: […] have this good rapport and relationship with your patients, and they will follow what you're saying.

Consumers' confidence in their expertise
There were strong expectations from consumers in this study for GPs to respect their opinions and take them seriously. This appeared to be due to several reasons. Consumers tended to report strong confidence in their knowledge and capacity to manage their con-

| Addressing consumer mental health
Mental health issues were discussed often in this cohort and were reported to impact significantly on the overall patient experience.

| Summary of findings
In this study, consumer expectations were based strongly on the context of their ongoing therapeutic relationship with a regular GP.
These expectations were as follows: maintaining a long-term relationship with the same GP, having good rapport, being respected for their knowledge and opinion, having effective communication and having their mental health addressed.

| Comparison to other research and practical implications
Participants identified that the consumer-GP relationship, in which expectations are communicated and responded to appropriately, is important to consumer experience of clinical interactions in general practice. For those with chronic conditions, these experiences were not necessarily based on individual clinical interactions, but in the context of an ongoing relationship with the same GP. This is not surprising given that the management of chronic conditions is often a long-term endeavour shared with the GP. 4,7 Relational continuity appeared to be related to and reinforced by other interpersonal expectations. For instance, having the same GP contributed to a sense of trust and comfort that enhanced the quality of clinical rapport and of interpersonal communication.
This expands on previous literature about the importance of sustained therapeutic relationships to the care of those with chronic conditions. [28][29][30][31] In our study, GPs reported that relational and informational continuity facilitated more effective consultations, as well as better overall management of patients. Previous research has similarly shown that continuity of care helps GPs perform clinical tasks more effectively, including improving the diagnosis and management of chronic and complex conditions. 30,31 In this study, relational continuity also enabled GPs to develop a deeper understanding of their patients as individuals with multifaceted needs, which is often viewed as being crucial to the delivery of patient-centred chronic care. 32,33 Ongoing interactions with the same GP have important implications for shared decision-making. By becoming more familiar with each other over time, consumers and GPs are able to negotiate how their expectations and priorities will be met during clinical interactions. We found that this not only gives consumers an idea of what to expect from current and future interactions, but it also enables them to feel comfortable enough with their GPs to express them openly. The links between therapeutic relationships, development of expectations and effective communication are integral to patient management and deserve further exploration in research. 34,35 Feeling respected for their expertise and opinions was another important consumer priority that was identified in the study.
Consumers discussed their confidence in their perceived health and health-care literacy to navigate and use services effectively.
Literature supports the notion that health literacy is a 'generative' skill, or an ongoing process that develops over time through While our GP participants acknowledged the value of seeking consumer knowledge, the collection and use of consumer feedback are not formalized in Australian general practice, highlighting a need to address this gap in both clinical practice and at a policy level. 38 Consumers also raised the importance of addressing mental health needs in addition to their chronic physical illness. The strong association between chronic physical illness and depression and anxiety has been documented in literature. [39][40][41] The association goes both ways: depression and anxiety are more common in those with a chronic physical illness than the general population 39   Many of the GPs who were included in the study also represented a unique subset of their peers due to the way they were recruited. Initially, GPs who were known to the researchers were invited to participate. These individuals were clinicians who had previously participated in or expressed interest in research activities in improving patient care. Some of the GP participants were also actively involved in the area as clinician-researchers or they had academic appointments and were also GP educators. Further snowball sampling of GPs through the participants' own contacts completed the recruitment process. For those who were not recruited through a research-related network (eg through the PHN directories), there was still a self-selection of clinicians who were interested in the topic, since there were no other incentives provided for participation. As such, and as reflected in the richness of the interview data, these participants seemed well-versed and keenly motivated to learn more about patient-centred care in general practice. This was both a strength and limitation because while this may limit our ability to generalize study findings, we were able to capture the rich perspectives of those with a strong interest in the research topic. This is important for a study like ours which is the first of its kind to explore this topic in depth.

| Study limitations and areas for future research
Additionally, despite efforts to recruit from culturally and linguistically diverse regions of Sydney, this level of diversity was not reflected in our study sample, particularly in our patient cohort.
We surmise that this may have been partly due to the English lan- Finally, because of this study focused on people with chronic conditions with a regular GP (ie median duration of seeing same GP was 8 years), the findings may not be transferable in the context of those with more acute needs and without a regular GP. The strong emphasis on relational continuity may be less significant to this group of consumers.

| CON CLUS ION
This study found that for consumers managing a chronic condition, expectations of general practice interactions were heavily based on their ongoing relationship with a regular GP. Within this context, GPs and consumers prioritized a continued, long-term relationship which facilitated positive rapport, respected consumer expertise, effective communication and attention to consumer's mental health. An important area for future research would be to test these expectations and see how they are being met in general practice settings. These findings may inform the way that GPs engage and make decisions with chronic disease patients. We recommend that assessing consumer expectations needs to be a crucial component of evaluating their general practice experience.

ACK N OWLED G EM ENTS
The authors would like to acknowledge the staff of Centre for Primary Care and Equity in their assistance in pilot testing and finetuning the interview guides. We would also like to thank Health Consumers New South Wales in advertising our study to their readership and all volunteers for participating in the interviews. The research reported has been conducted as part of the author's (HJS) doctoral study at the University of New South Wales. Funding was provided as part of her scholarship.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.