Obstacles to shared care for patients with dementia: A qualitative study

Background. All Primary Care Trusts in England were meant to have shared care protocols for antidementia medication use in place by 1 April 2004. Shared care of medical treatment in dementia depends upon early diagnosis, but under-recognition of and under-response to dementia appear widespread in general practice. Aim. To investigate the perceptions of specialists and generalists about the potential for shared care of people with dementia. Design of study. Qualitative study with semistructured interviews. Setting. Three inner-city and two rural areas. Methods. Semistructured interviews were arranged at the participants' convenience and were tape-recorded and transcribed. Thematic analysis of the anonymized transcripts was undertaken and a case and cross-case analysis was performed. Results. Thirty-nine GPs and 30 specialists were interviewed. Broad themes were reduced to following four key categories which appear to be layered over each other: therapeutic nihilism; risk reduction or avoidance; concerns about competency; and resources for shared care. Conclusion. Roles for primary and secondary care professionals are inappropriately distributed and require clearer definition. Resistance to shared care mostly comes from within general practice and reflects concerns about staffing, time constraints, lack of experience and confidence in making and disclosing a diagnosis. Developers of shared care protocols must dissect layered obstacles, addressing the issues of therapeutic nihilism, risk management and clinical competence.