Abstract

Introduction
Sleep problems are common with perceptions that management should be improved in general practice. There is considerable evidence of underuse of sleep assessment tools and psychological treatments such as cognitive behavioural therapy for insomnia (CBTi), continuing evidence of inappropriate long term prescribing of hypnotics and a perception of poor practice among patients and practitioners. The Resources for Effective Sleep Treatment (REST) project aimed to study new approaches and models for implementing sleep assessment methods and CBTi into routine practice in a large rural county as part of a wider quality improvement programme.

Method
We used a multiple case study approach and logic model to describe how we approached the problem of engaging general practitioners in improving sleep management. Using practices as the units of analysis we describe how we (re)framed the problem, developed solutions and saw the impact of these on changing practice. We used qualitative and time series analysis of prescribing to show changes in care over time.

Results
Within two years of starting, over one third of practices had participated in the quality improvement project with evidence of change in routines in some practices. We gathered evidence on what care patients currently received and what they needed, how practitioners responded and how they could change practice, how practice teams redesigned processes of care and the impact of these changes on quality of care and prescribing for sleep problems.

Discussion
We used a range of approaches to understand the need for and receptiveness to change in management of sleep problems, how change could be introduced into general practice and how these changes could be spread more widely. Potential problems of generalisability were addressed through triangulating evidence. An approach using multiple methods sequentially and concurrently, to understand the problem of sleep management and how to improve it, has helped inform development of a multidisciplinary model for management of sleep problems in primary care. ‘Problem focused therapy’ uses a consultation approach comprising careful assessment and use of modified CBTi for insomnia, which if adopted more widely will potentially improve the quality of patient care in the primary care treatment of insomnia.