Técnicas de estrés

Few of the GPs offered alternative practice arrangements which would facilitate a more concentrated focus on childhood obesity, although one GP had set up a daily lunch time clinic which covered all child health issues. It was noted by two of GPs that the infrastructure and organisation of general practice was not sufficiently flexible to offer group work for children, nor would the numbers of children in the practice support such investment. A small number of GPs finally talked about wider weight management programmes for children.In the main they regarded primary care intervention as just one part of a broader co-ordinated approach to tackling childhood obesity problems and were particularly keen to see better education about food and physical activity in schools and wider multi agency public health programmes in the community. They also indicated that they would strongly support interventions that were focused on encouraging children and families to make healthy lifestyle changes, rather than any acute interventions, “we are highly unlikely to be looking at any bariatric surgery for

children,” (GP No. 1). Interestingly, the options that the GPs considered focussed on fun, social, safe and supporting group activities. One GP believed that programmes like MEND3 should continue to be commissioned because of its focus on addressing family issues and supporting and empowering parental engagement. The need for a wide range of public health responses was also acknowledged given the previously expressed complexities of childhood obesity, “there needs to be a big team, school nurses tackling school meals, PE teachers,

parents, all these aspects are important.” (GP No. 8). GP No. 3 felt that public health commissioners should lead on more holistic approaches to childhood obesity prevention, and that the key way to secure wide scale improvements would be through a more co-ordinated, strategic approach. Whilst most of the GPs could see the value in having more local community based family intervention activities, they did not recognise that they had a role in advocating for such.

101 4.6. Summary.

The findings highlighted in each of the four super-ordinate themes, have revealed a rich and diverse range of factors which impact iteratively on the decision making processes that the GPs engage in, in order to identify and respond to the children who are obese. These processes are shaped by their understanding of the family and updated by the experiential evidence that the GPs encounter in their daily practice. The findings confirmed the breadth and variability of the diverse considerations, and the blend of knowledge and reasoning that the GPs took into account when deciding what to do and what to say to the family. The decision making process appeared to involve a rapid synthesis of known familial characteristics, behaviours, beliefs and motivations. However, alongside this complex but relatively stable, foundational knowledge of the family there were also more dynamic and fluid situational factors which influenced the final decision as to whether to raise the topic of the child’s weight with the family and spend time on this issue. Sometimes the decision to raise the topic of the child’s weight with the family were judiciously based on time available, or the staffing resources within the practice, or the priority they gave to this child’s issues over the cascade of other extraneous pressures and demands they faced at that time. The decision making process seemed ambivalent to known guidelines issued by NICE (2006), the Department of Health (2011) and the Royal College of Physicians (2013). Similarly, the decisions about managing the child’s weight tend to be pragmatic and iteratively negotiated between the family, the GP and sometimes the child. At the heart of this was an overwhelming need to sustain, wherever possible, the relationship between the GP and the family. The majority of the GPs explored how they experienced the most difficulties when the outcome the parents wanted was to address the child’s personal psychological or social problems caused by obesity, such as bullying, lack of self - esteem or social isolation from their peers. The GPs were clear that such skills or knowledge were not necessarily in their repertoire, which caused conflicts for the GPs in terms of both role adequacy and legitimacy. It was also clear that there were mixed views about which services could support any psychological consequences of the child’s obesity.

The findings also highlighted how the GPs’ attitudes towards the parents, their own personally held health beliefs relating to preventative medicine and their role in this, and their overall understanding and perceptions of childhood obesity varied from GP to GP. For each GP it appeared that they accounted for their decision making as a resolution of their own particular set of motivators, competences, levels of confidence, values and beliefs. Moreover

102

it appeared that their attitudes to childhood obesity, whilst derived from their clinical training were also constantly modified by their experiences and interactions with parents in the consultation room, what they saw on television, what they read about in newspapers even what they saw in the supermarkets. It was clear from the ideographic analysis, that the GPs’ attitudes were often framed outside of the medical discourse and referenced not only societal and cultural attitudes to childhood obesity, but also those relating more widely to norms and expectations regarding what constituted good parenting especially in relation to actively promoting the health of the child.

The GPs had varied views about their experiences of working with children and families. Some were concerned about the loss of active engagement with child health more generally which was completed in other settings by other professionals, and which led the GPs to acknowledge that some of their skills and experience in this area had been diluted. Whilst the GPs reflected that many of their experiences were complex, on the whole, the GPs felt that they could and should intervene, particularly with very obese children and their families. It appeared that the more the child moved along the spectrum towards being perceived as clinically obese, the more legitimate they felt in their decision to intervene. Overall they believed that intervening with children and their families was an important but challenging task. However the GPs articulated a range of practical limitations which included a lack of referral pathways and limited support from other staff and services.

103 Chapter 5: Discussion.

5.1. Introduction.

The findings outlined in Chapter 4 reveal complex and varied discourses in the GPs’ description of their consultations and responses to the children who are obese. They also present the GPs’ multiple and complex views regarding their roles, approaches, attitudes and motivations. This study has therefore added significantly to previous findings where GPs’ responses tend to be presented and considered as one homogenous professional group (Walker et al., 2007; Turner et al., 2009). In this chapter, Section 5.2 will respond to the initial aim of the research which was to explore GPs’ experience of identifying and managing children who are obese in a primary care setting, by providing a more detailed exploration and discussion of the complexities highlighted by the GPs in each of the super-ordinate themes. The intention is to consider the findings in relation to the existing literature presented in Chapter 2.

Section 5.3 will address the second aim of the research, namely to identify variations in the accounts which impact upon the type of responses that GPs provide. This will be achieved by presenting a continuum of GP role types linked to the aligned underlying epistemological frameworks of the GPs, as a new and innovative way of exploring and discussing this complex area of clinical practice. Section 5.4 will focus on the limitations of the research. Chapter 3 highlighted that IPA involves an inductive, intense, interpretative analysis, (Smith et al., 2009). It is important to acknowledge that the analysis and discussion presented below will therefore be framed in the inevitable subjectivity inherent when there are multiple levels of interpretation. In presenting the evidence, categorising and organising the content, it is the researcher who has selected what counts as relevant material. Finally as this research is presented as a Professional Doctorate, with an ambition to “further advance or enhance

professional practice” (Lee, 2009, p.7), this chapter will also focus on areas that can make a contribution to professional and policy recommendations regarding the potential opportunities and limitations of GPs’ contribution to the identification and management of childhood obesity. Chapter 6 will address the third aim of this research to produce practical suggestions for improving service provision.

104 5.2. Discussion of the super-ordinate themes.

This section will highlight and discuss areas in each of the super-ordinate themes that reflect, extend and expand on the existing literature on GP decision making regarding identification and management of childhood obesity. It will discuss the reality of clinical practice as presented by the GPs, and highlight both the potential opportunities and limitations of GPs’ contribution to the identification and management of childhood obesity.