A feasibility study as part of a programme of work (CHOICE; NIHR RP-PG-0707-10162). Ethical approval from NRES Committee North West- Greater Manchester East, REC reference: 12/NW/0068.
Two practitioners, whom we called Liaison Health Workers (LHWs), were seconded to the study. Both were female. One had mental health nursing background; the other general nursing and mental health social work. Training, delivered over two days by a professor of liaison psychiatry and professor of mental health, included skills training (patient-centred interviewing and problem solving), psychological interventions, behavioural activation, cognitive restructuring, medication management and liaison skills. Training ended with observed consultations with a simulated patient. In addition, the LHWs shadowed members of the COPD Service at a local hospital, and identified relevant local third-sector services and networks including voluntary groups, Expert Patient Programmes and advice centres. Their work was guided by a treatment manual, which emphasised working with patients to: identify and prioritise psychosocial and clinical needs; address psychosocial needs directly; and liaise with practice staff around clinical needs. They offered self-help booklets and relaxation CDs to patients, sign-posted patients to third sector services, as they judged appropriate, and addressed patients’ social problems (see below). The LHWs received twice-weekly individual or joint supervision from a liaison psychiatrist. Treatment sessions were audio-recorded and re-played in supervision to assess treatment fidelity.
The LHWs were based in the participating general practices, where they had access to electronic patient records on which they documented their activity . They saw patients either in their own homes or occasionally at the practice, or spoke with patients by telephone. They provided up to four sessions, with an option of a further four if required, of up to about one hour each. They chose to wear nurse uniforms and introduced themselves to patients as Liaison Health Workers based in the patient’s general practice.
Participating practices and prospective participant patients received an information leaflet ‘Coping with COPD: How can Liaison Health Workers help?’, individualised with the practice name and LHW contact information, and containing brief information about the LHW and what she could offer. Recruited patients also received a card including a photograph of the LHW and her name and contact information and a plastic wallet to store material provided by the LHWs.
We used data from Central and South Manchester Primary Care Trusts (now Clinical Commissioning Groups) to target practices with a high prevalence of COPD, recruiting six, of which three were randomised to receive the LHW intervention. Participation in the study was accepted by the Primary Care Trust to meet the requirement for delivery of one of the QP (Quality and Productivity) indicators for the Trust.
The intervention was introduced to practices in one or two (determined by the practices) half-day workshops by a professor of liaison psychiatry and professor of primary care, who outlined the research programme and detailed the intervention. In addition, they discussed with practices the potential to improve internal communications about management of COPD and to improve detection of patients’ psychosocial needs. Each practice was encouraged to consider how to maximise the benefit from the LHWs’ work, and to integrate them as much as possible into practice systems, such as providing a consultation room, filing space, access to practice computer systems (EMIS) to share patient information, and access to team meetings.
Patient recruitment to the intervention
As a pragmatic trial of a clinical service embedded within GP practices, the inclusion criteria for referral to the LHWs were simple and broad with the specific intention to enhance the external validity of the study. Patients were accepted for treatment if they had a QOF diagnosis of COPD and at least one indicator of psychosocial need, which included a QOF diagnosis of depression, clinical diagnosis of depression by practice staff, social isolation, and chronic or recent psychosocial stressors. Pathways for recruitment included direct referral from GP or other practice staff, and invitation by a letter (enclosing an information leaflet about the LHW service) for patients on the QOF depression register. Of 467 patients on the practices’ COPD registers, 184 were invited to see the LHW (of whom 51 had a QOF diagnosis of depression).Recruitment is detailed in Figure 1. Of 184 patients invited to see the LHW; 97 agreed and 81 completed the intervention (defined as completing 4 meetings or being discharged by mutual agreement after fewer). For recruitment to the qualitative evaluation we adopted maximum variation sampling whereby we sought patients across the range of co-morbidities and ages of those available, at a range of intervals after the intervention ended (from one week to 5 months), and we made strenuous efforts to recruit those who declined or withdrew from the intervention. We excluded patients on a palliative care register. Patients who completed the intervention received a Patient Information Sheet (PIS) describing the qualitative evaluation and a reply slip on which they could indicate willingness to be interviewed and a prepaid envelope. Of 67 patients who indicated willingness to be interviewed, we interviewed 26. Of 57 patients who declined the intervention we sent the PIS and reply slip to 51, of whom one agreed and was interviewed. Of 20 patients who withdrew before completion, we invited 17 to be interviewed, of whom 2 agreed and were interviewed.
We asked staff at the participating practices to participate in interviews. Of 14 general practitioners (GPs), 6 practice nurses (PNs) and health care assistants (HCAs), and 4 administrative staff whom we invited, 5, 4 and 4, respectively, agreed and were interviewed. All participants received written information about the study and provided written consent for interview.
Data collection and analysis
We used interviews because we wanted to ascertain patients’ and HCPs’ views and experiences. Patients took part in semi-structured interviews (mean 47 minutes) in a private area at the practice or in their homes, as they preferred. Interviews were guided by a topic guide which included: their health difficulties and psychosocial context; expectations of the LHW; experience of the LHW’s involvement, including benefits or difficulties associated with it; comparison with other services currently or previously encountered; and reflections on the intervention over the time since it ended. Practice staff were interviewed in a private area of their practice (mean duration 30 minutes, range 15–40). The interview topic guide included their expectations and experience of the LHWs, including effects on patient care or the practice and (for practitioners) whether and why they referred patients to the LHWs. The researchers conducting the interviews (SL, CH, KK) had previous experience including mental health (all), and long-term conditions and primary care (SL, CH) and were each trained in qualitative interviewing and supervised by the study team. They were independent of the intervention and clinical teams; contact with the LHWs was confined to research tasks. The intervention was time-limited and data collection ended when it came to a close.
Data were anonymised and transcribed verbatim. Analysis was inductive and took a constant comparative approach. The researchers familiarized themselves with the transcripts, and discussion amongst the team identified themes documented in a set of continually updated analysis notes. We paid particular attention to deviant cases that modified our initial analysis. In presenting illustrative data below, we identify participants by numbers. The ellipsis (...) signifies omitted text. Square brackets denote explanatory text. Illustrative quotations are labelled with the practice identifier (R,G,B) and patient identification number and, for staff, the staff category.
To characterise the sample, patients completed two self-report questionnaires at the start of the first meeting with the LHW: PHQ-9  and GAD-7  to assess depression and anxiety, respectively.