The sample consisted of 30 stakeholders (18 men, 12 women) from various backgrounds. Most were involved in two (n = 12) or three (n = 3) domains. Patients were represented by three persons with a chronic illness and two board members of a national patient federation (one of whom had recently moved to a professional association for PNs). The sample included six GPs and three PNs. Mental health care was represented by two participants involved in professional associations of primary care mental health workers and one psychiatrist. Three participants were involved in medical education (training GPs and PNs). Three participants were involved in the development of national guidelines. The sample also included two health insurers and two health inspectors. Four participants were involved in national health policy. Researchers (n = 11) included principal investigators and others involved in research on primary care, chronic care, mental health care, implementation science, and general practice. Most of them were also professionally involved in health care (n = 4), guideline development (n = 2), mental care (n = 1), national health policy (n = 1) or medical education (n = 2). Our data extraction was confirmed in the member checks.
Achieving a biopsychosocial approach to chronic care
Respondents underlined the impact of chronic conditions on psychosocial functioning and patients' needs for support in dealing with a chronic disease in everyday life. Although they considered a biopsychosocial approach to be inherent in being a primary care professional, respondents confirmed the current lack of a systematic approach in providing psychosocial care to patients with a chronic disease. The present use of the biopsychosocial model mainly depends on the individual skills of the professionals rather than on a well-planned strategy. Respondents perceived a need for simultaneous changes at various levels.
Recognition of psychosocial problems: a shared responsibility
Primary care professionals need to be aware that psychosocial care is an important adjunct to medical care. Both patients and professionals argued that it is difficult to determine when or whether health professionals should be involved, as psychosocial problems were perceived as belonging to the normal life of chronically ill people. Hence, neither doctors nor patients do sufficiently address psychosocial problems.
'What is the dividing line between a 'normal reaction' and a 'pathological reaction'? When does a mood problem turn into a depression? When is gloominess no longer acceptable?' [researcher]
Respondents attached great importance to providing care that starts from the perceived, multifaceted needs of patients. In this regard, interviewees emphasized that patients and their social environment need to play an active role in the whole care process. Their participation is crucial for the early recognition of psychosocial problems and for discussing them with a doctor during consultations.
'The patients themselves and their social environment obviously play an important role as well. The patient has to notice that this is more than just their chronic somatic disorder, that there is something wrong with their attitude, their situation, their mood. ... This care environment may also include the patient's relatives.' [researcher, health policy maker]
Some wondered how a health professional assesses patients' needs, or to what extent patients themselves define their needs. One patient noted that many (particularly older) patients are passive recipients of care, who look up to a health professional as an authority. Patients' expectations about psychosocial care in general practice seemed to be low, as they think health professionals do not have time to address this kind of problem or cannot empathize with problems the way fellow patients can.
Training of health professionals
Most respondents considered training to be a major facilitating factor to ensure that the biopsychosocial model becomes integrated in chronic care. Respondents representing educational institutes confirmed their intention to train their students to develop a joint focus on the biological, psychological and social dimensions of illness. However, they argued that teaching programmes should make a greater effort to teach students to start from the patient as a person rather than the disease.
'Right from the start of the courses in year 1, students should think in terms of patients and care needs. So the teaching courses really need to be changed. Doctors should not be trained so much to think in terms of diseases, but to think in terms of care needs.' [professional involved in research, teaching and guideline development]
Primary care professionals (especially GPs and PNs) should be sensitized to identify psychosocial needs associated with medical health problems, and care providers in chronic care also need to be trained to work in multidisciplinary teams. Other issues that were mentioned included more training in communicative competencies like listening or recognizing nonverbal signals, and training to monitor patients' perceived problems in daily functioning.
Current guidelines for chronic care do not adequately integrate medical and psychosocial aspects, or multimorbidity. Multimorbidity can relate to multiple somatic diseases but also to psychosocial problems. Respondents mentioned the complicated task of incorporating and presenting all these aspects in conveniently structured guidelines. Some suggested allowing more room for the patient's perspective in guidelines, by involving patients in the guideline development process.
Quality assurance indicators, preferably derived from clinical practice guidelines, were also mentioned. To date, outcome parameters have been dominated by biomedical indicators such as HbA1c (blood sugar level). The public health quality indicators defined by the Dutch Health Inspectorate also include only biomedical parameters. Respondents underlined the need for process and outcome quality indicators for psychosocial care.
There is no interest in my patients' quality of life, which is what should really be the performance measure. In practice, your performance is judged on the basis of very simple outcome measures - × number of decimals of the HbA1c values. [GP, researcher]
The majority of respondents said hat GPs and PNs needed additional tools such as questionnaires to help them with signalling, diagnosing and selecting interventions, as well as monitoring and evaluating biopsychosocial care. Several respondents mentioned systematic screening to identify patients with a need for psychosocial care, while at the same time being cautious about the downside, i.e. the generation of false-positive screening results. Some suggested a stepwise method of case-finding to differentiate between mild, moderate and serious problems and to provide care that fits the patient's needs. In addition to tools to detect specific issues (like social isolation or poly-pharmacy), respondents asked for communication techniques or less laborious assessment instruments to identify individual patients' needs.
'My ideal, if we could start again, would be that I should diagnose, for instance, a diabetes patient, that of course we offer all the options that science has to offer, but that in addition to that we'd have a kind of list, 10 to 20 points, that you take the patient through to see what their problems are in everyday life. ... Using the doctor's experience to list current problems and expectations and then check the same list every year or so to see if you are still working on the same goals.' [GP, researcher]
Integrated primary care
Respondents perceived an integrated primary care system as one of the cornerstones of biopsychosocial care, involving clearly defined pathways and effective teamwork among all caregivers in primary and secondary care.
What we need is a closely integrated first-line health care system, with clear lines. Everyone involved should know their own place in the collaborative model.' [GP, researcher]
Disease management programmes that include prevention, monitoring and treatment might already represent a step forward to integrated chronic care. However, some caution is needed as these programmes are still driven by diseases rather than by patient needs.
Some pointed out that integrated primary care starts within the small-scale setting of a GP practice. Delegation of tasks from GPs to PNs, practice assistants and/or nurse practitioners, and the variety of responsibilities and specialities makes effective teamwork very complex. In addition to this, there are several kinds of mental health care professionals involved in Dutch primary care. This highlights the need for a clear division of tasks, responsibilities and communication processes among the various health professionals.
'A sort of step-by-step plan: what aspects should be the responsibility of the GP, what should be done by a psychiatric nurse? As a practice nurse, you need to be aware of your limitations. There comes a point where I have to say: this is beyond my professional competence, and should be dealt with by the practice psychiatric nurse.' [Health care professional]
Some emphasized that GPs should remain primarily responsible for the patient's care process. Others mentioned that PNs are increasingly taking on a coordinating case-manager role for chronic patients. A concern was that PNs who provide care for patients with a physical chronic disease may not correctly identify and treat psychosocial problems, since they have little experience with psychological and social health problems.
Financial issues
The professionals mostly mentioned a lack of time to incorporate psychosocial care in their routine practice. Time constraints were related to the available consultation time, workload and financial constraints. In this regard, respondents commented on the payment system for primary care. Some emphasized the potential benefits of the Dutch reimbursement system, which offers all-inclusive payment for people with chronic conditions to a multidisciplinary team. This stimulates the delivery of efficient and integrated chronic care. However, the emphasis on diagnosis-treatment combinations (DTCs) rather than on aspects like comorbidity or multimorbidity does not encourage professionals to start from the multifaceted biopsychosocial needs of individual patients.
'I'm not against DTCs at all; I think they're the best way to work in an output-driven manner. I really think they are necessary in health care. But you may wonder whether the current DTC concepts are useful. I could imagine that I might see a patient and think I will define a DTC not with the aim of treating the disease but actually treating the patient. Looking at the patient in a holistic manner. That's the right way.' [professional involved in research, teaching and guideline development]
Respondents argued that psychosocial care should be a general module within all DTCs. This would mean making it an integrated part of all national care standards on which health insurers base their payments. If no reimbursement is given, professionals in the field will not systematically include this aspect in their daily care.
Research
The majority of respondents mentioned research as an essential prerequisite for achieving a biopsychosocial approach to care. If interventions are to be incorporated in care standards and hence included in the reimbursement fees, they have to be evidence-based. The development of evidence-based biopsychosocial self-management interventions needs to be given greater priority on the research agenda of major funding organisations. Respondents preferred intervention research with patient-reported outcomes such as quality of care, patient satisfaction and healthcare consumption. However, this kind of research is complex among patients with comorbidity or multimorbidity, and patients with multifaceted health problems are often excluded. Respondents also suggested more research with the aim of improving integrated primary care. In addition, they stressed the importance of research into the patients' needs.