Abstract

Introduction
Sleep problems are common with scope for improving sleep management in general practice. There is considerable evidence of inappropriate long term prescribing of hypnotics and underuse of psychological treatments such as cognitive behavioural therapy for insomnia (CBTi). We aimed to investigate practitioners’ experience of the feasibility and practicability of implementing sleep assessment tools and non-pharmacological interventions for sleep management in primary care.

Method
We set up a Quality Improvement Collaborative (QIC) with eight general practices in Lincolnshire, East Midlands, UK as part of the Resources for Effective Sleep Treatment (REST) project to study potential new approaches for implementing sleep assessment methods and CBTi in practice. The project team met monthly with practice teams to share learning about sleep management and data were collected using audiotapes to understand the facilitators, barriers and changes that practices were making as a result of the QIC. Audiotapes were transcribed verbatim and thematic analysis was carried out with the aid of MAXQDA.

Results
Meetings with each practice team (2 each) and the collaborative group (4) during the QIC were analysed. Nine themes emerged: engagement of staff, practitioner views of different tools, barriers to implementing the sleep tools and techniques, practitioner and patient preconceptions and expectations of treatment, educational and support needs of patients and staff, changes initiated/to be initiated by practices and the importance of a tailored approach.

Discussion
Practitioners’ preconceptions, attitudes, beliefs and educational needs needed to be addressed for successful implementation of sleep tools and techniques.

Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care.

A collaborative approach utilising quality improvement techniques informed development of an interdisciplinary model for management of sleep problems in primary care: ‘problem focused therapy’. This uses a consultation approach comprising careful assessment and use of modified CBTi for insomnia in the consultation, which is being investigated in an exploratory randomised controlled trial. If ‘problem focused therapy’ is successful then we expect a substantial improvement in the quality of patient care in the primary care treatment of insomnia.