Implementing change in primary care practice: lessons from a mixed-methods evaluation of a frailty initiative

© 2018, BJGP Open. Background: The NHS is facing increasing needs from an aging population, which is acutely visible in the emerging problem of frailty. There is growing evidence describing new models of care for people living with frailty, but a lack of evidence on successful implementation of these complex interventions at the practice level. Aim: This study aimed to determine what factors enable or prevent implementation of a wholesystem, complex intervention for managing frailty (the PACT initiative) in the UK primary care setting. Design & setting: A mixed-methods evaluation study undertaken within a large clinical commissioning group (CCG). Design and analysis was informed by normalisation process theory (NPT). Method: Data collection from six sites included: observation of delivery, interviews with staff, and an online survey. NPT-informed analysis sought to identify enablers and barriers to implementation of change. Results: Seven themes were identified. PACT was valued by professionals and patients but a lack of clarity on its aims was identified as a barrier to implementation. Successful implementation relied on champions pushing the work forward, and dealing with unanticipated resistance. Contracts focused on delivery of service outcomes, but these were sometimes at odds with professional priorities. Implementation followed evidence-informed rather than evidence-based practice, requiring redesign of the intervention and potentially created a new body of knowledge on managing frailty. Conclusion: Successful implementation of complex interventions in primary care need inbuilt capacity for flexibility and adaptability, requiring expertise as well as evidence. Professionals need to be supported to translate innovative practice into practice-based evidence

Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice

Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients' health and wellbeing is instead becoming part of the problem. The way we practice medicine has become a driver for the problem. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of compromise into the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and, in our understanding of the process of research, how we generate the knowledge that informs practice. This review considers the current state of play in all 3 areas and identifies some of the work we still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health

Primary care redesign for person-centred care: Delivering an international generalist revolution

© La Trobe University. Person-centred primary care is a priority for patients, healthcare practitioners and health policy. Despite this, data suggest person-centred care is still not consistently achieved-and indeed, that in some areas, care may be worsening. Whole-person care is the expertise of the medical generalist-an area of clinical practice that has been neglected by health policy for some time. It is internationally recognised that there is a need to rebalance specialist and generalist primary care. Drawing on 15 years of scholarship within the science of medical generalism (the expertise of whole-person medical care), this discussion paper outlines a three-tiered approach to primary care redesign describing changes needed at the level of the consultation, practice set up and strategic planning. The changing needs of patients living with complex chronic illness has already started a revolution in our understanding of healthcare systems. This paper outlines work to support that paradigm shift from disease-focused to person-focused primary healthcare

Realising the full potential of primary care: uniting the ‘two faces’ of generalism

Faced with an unprecedented mismatch between presented health needs and resources available, we must rethink both how we deliver healthcare and what care we deliver. Work has already started on the ‘how’: notably with efforts to strengthen access and integration (improved coordination of the comprehensive care needed to meet a diverse range of needs). It is defining ‘what’ to deliver that is proving more challenging. To address emerging problems of over- and under-treatment associated with the undue specialisation of healthcare, we need to strengthen delivery of generalist medical care. Meaning we need to bolster capacity to decide if and when medical intervention is the right approach for this individual (whole person) in their lived context. We need to put the interpretive expertise of the medical generalist back at the core of our primary healthcare systems

Tackling overdiagnosis : supporting the re-emergence of generalist expertise

Overdiagnosis – the problem of too much medicine (1) - is big business. Literally so, as described in the writing offered by the pharmaceuticalisation and medicalisation critiques (2). Transforming ever more of human existence in to a medical condition to be diagnosed and treated offers promise of ever greater market share to big companies around the world. But also figuratively speaking, if we look at the growing array of papers, journals, and conferences which discuss and debate the phenomenon

Insights into the impact of clinical encounters gained from personal accounts of living with advanced cancer.

Aim To describe the impact of interactions with health care professionals revealed by people’s accounts of living and dying with cancer; to explore reasons for the observed effects; and thus, to consider the implications for practice. Background The importance of practitioner–patient interactions is enshrined within professional values. However, our understanding of how and why the consultation impacts on outcomes remains underdeveloped. Stories recounted by people living and dying with cancer offer important insights into illness experience, including the impact of contact with health services, framed within the context of the wider social setting in which people live their lives. From our recent study of distress in primary palliative care patients, we describe how people’s accounts revealed both therapeutic and noxious effects of such encounters, and discuss reasons for the observed effects. Method A qualitative study with a purposive sample of 19 primary palliative care patients: (8 men, 11 at high risk of depression). In-depth interviews were analysed using the iterative thematic analysis described by Lieblich. Findings Living with cancer can be an exhausting process. Maintaining continuity of everyday life was the norm, and dependent on a dynamic process of balancing threats and supports to people’s emotional well-being. Interactions with health care professionals were therapeutic when they provided emotional, or narrative, support. Threats arose when the patient’s perception of the professional’s account of their illness experience was at odds with the person’s own sense of their core self and what was important to them. Our findings highlight the need for a framework in which clinicians may legitimately utilize different illness models to deliver a personalized, patient-centred assessment of need and care. The work provides testable hypotheses supporting development of understanding of therapeutic impact of the consultation

Measuring medicine-related experiences from the patient perspective: a systematic review

Background There is an increasing drive to measure and so improve patients’ experiences and outcomes of health care. This also applies to medicines, given their ubiquity as health care interventions. Patients’ experiences of using medicines vary and instruments which measure these are seen as an essential component to improve care. We aimed to identify generic measures of patients’ experiences of using prescription medicines and to examine their properties and suitability for use in research or practice. Methods Multiple electronic databases were searched: Medline, Embase, PsycINFO, PsycARTICLES, CINAHL Plus, the PROQOLID®, and Google Scholar. We identified, critically appraised and summarized generic questionnaires assessing one or more aspects of the medicine use experience among adult patients using prescription medicines for chronic conditions, and the process of questionnaire-development, degree of patient-involvement, and/or validation processes. Results 15 questionnaires were included. Of these, nine measures were multidimensional, covering various aspects of medicine use. Six instruments covered only a single domain, assessing a specific facet of using medicines. Domains covered were: effectiveness; convenience, practicalities and/or managing medicines; information, knowledge and/or understanding; side effects; relationships and/or communication with health professionals; impact on daily living and/or social life; general satisfaction; attitudes; beliefs, concerns, and/or perceptions; medical follow-up and/or adherence-related issues; treatment- and/or medicine-related burden, perceived control or autonomy; self-confidence about medicine use; availability and accessibility; and medicine-related quality of life. None of the identified questionnaires covered all domains. Instruments varied in the extent of both patient involvement in their development and in validation. Conclusion There is a scarcity of psychometrically sound, comprehensive, generic measures of experiences of using prescription medicines among adult patients living with chronic illnesses. There is a need for further development and/or validation of existing instruments suitable for use in this populatio

Person-centred medicines optimisation policy in England: an agenda for research on polypharmacy

Aim: To examine how patient perspectives and person-centred care values have been represented in documents on medicines optimisation policy in England. Background: There has been growing support in England for a policy of medicines optimisation as a response to the rise of problematic polypharmacy. Conceptually, medicines optimisation differs from the medicines management model of prescribing in being based around the patient rather than processes and systems. This critical examination of current official and independent policy documents questions how central the patient is in them and whether relevant evidence has been utilised in their development. Methods: A documentary analysis of reports on medicines optimisation published by the Royal Pharmaceutical Society (RPS), The King’s Fund, and National Institute for Health and Social Care Excellence (NICE) since 2013. The analysis draws on a non-systematic review of research on patient experiences of using medicines. Findings: The reports varied in their inclusion of patient perspectives and person-centred care values, and in the extent to which they drew on evidence from research on patients’ experiences of polypharmacy and medicines use. In the RPS report, medicines optimisation is represented as being a ‘step change’ from medicines management, in contrast to the other documents which suggest that it is facilitated by the systems and processes that comprise the latter model. Only The King’s Fund report considered evidence from qualitative studies of people’s use of medicines. However, these studies are not without their limitations. We suggest five ways in which researchers could improve this evidence base and so inform the development of future policy: by facilitating reviews of existing research; conducting studies of patient experiences of polypharmacy and multimorbidity; evaluating medicines optimisation interventions; making better use of relevant theories, concepts and tools; and improving patient and public involvement in research and in guideline development