Enablers of and barriers to change in primary care: a process evaluation of an adaptable guideline implementation strategy
There are well documented and often inappropriate variations in adherence to evidence-based guidelines amongst general practices, with subsequent inequities in quality of care and patient outcomes. However, there are challenges in addressing this within the pressures and demands of UK primary care.
Action to Support Practices Implementing Research Evidence (ASPIRE) developed and evaluated an implementation intervention adaptable to different targeted guideline priorities. The intervention included audit and feedback, educational outreach, pharmacist support, computerised searches and prompts. A pair of cluster randomised trials were conducted in practices across West Yorkshire, UK. Randomised practices received interventions targeting one of: blood pressure control in patients at high risk of cardiovascular events; type 2 diabetes control; anticoagulation for stroke prevention in atrial fibrillation; and high risk prescribing. A parallel process evaluation examined: how the intervention was received and enacted; whether the intervention became embedded in routine work; and whether the intervention had any unintended consequences. Eight general practices participated (two per targeted clinical area). Data were collected from observations, semi-structured individual and group interviews, a fidelity survey and document review. Framework analysis drew upon Normalization Process Theory and the Theoretical Domains Framework.
Practices believed in the value of improvement in the targeted clinical areas. Practices initially responded well to feedback, valuing comparisons to their previous achievement and that of other general practices. However, some practices found feedback anxiety-provoking and disheartening as the year progressed. The intervention seemed to work best where practices were able to limit involvement to individual staff with capacity to independently fulfill tasks. Where tasks were split across teams, practices seemed less likely to improve and some teams disengaged. Outreach support, where initial note reviews were completed for practices, was valued for rationalising workload and highlighting key gaps. Searches enabled speedier engagement with more complex clinical work. Practices were enabled to achieve progress by clear links between individual actions and desired outcomes, administrative staff involvement in monitoring achievement, and alignment of work with other priorities (e.g. clinical commissioning group medicines management). Progress was disrupted by interventions being subsumed into another initiative (e.g. Quality and Outcomes Framework), staff shortages and other pressures restricting opportunities for team reflection, and resistance to team-level re-organisation.
Whilst intervention components were acceptable to practices, potential emotional and motivational effects of feedback need to be further investigated. Likewise, whilst co-existing initiatives could enable engagement, being too closely aligned with one could promote resistance and fatigue, especially where systems were already structured around existing initiatives. Achieving and sustaining change in evidence-based practice are likely to require both a systematic mechanism of reflexive monitoring and clear differentiation of work from other activities; change is unlikely to occur if practices feel overburdened with existing initiatives.