• Bruno Rushforth, Carolyn McCrorie, Liz Glidewell, Eleanor Midgley, and Robbie Foy.
• Foundry Lane Surgery, Leeds.
• Br J Gen Pract. 2016 Feb 1; 66 (643): e114e127e114-27.

BackgroundDespite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.AimTo guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians' and nurses' perceived influences on care.Design And SettingSystematic review of qualitative studies with findings organised using the Theoretical Domains Framework.MethodDatabases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians' or nurses' perceived influences on treatment goals for type 2 diabetes.ResultsA total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.ConclusionAlthough resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians' skills and emotions around treatment intensification and facilitation of patient behaviour change.© British Journal of General Practice 2016.

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