Exploring primary care staff experiences of financial incentives for implementing asthma self-management: a qualitative study in Northern Ireland using normalization process theory

Problem

In 2008, Northern Ireland introduced a healthcare scheme that pays a financial incentive to general practices for providing self-management education, including an asthma action plan, to patients with asthma. We aimed to explore how primary care staff responded to the introduction of this scheme and how they implemented new processes into their practice routines.

Approach

Qualitative interviews were conducted to explore staff response to the healthcare scheme and perceptions of its impact on the implementation of asthma self-management. Interviews were recorded, transcribed verbatim and analysed using a framework informed by the Normalization Process Theory (NPT).

Findings

23 participants (five general practitioners; five nurses; 13 administrative staff) involved with delivering the scheme from 15 primary care practices across Northern Ireland provided 15 semi-structured telephone interviews, six individual in-depth interviews and two group interviews. Processes created since the introduction of the scheme appear successfully embedded into primary care practice routines with many staff stating that they could not remember or did not know what the processes were prior to the scheme. Multi-disciplinary teams and working together were continually discussed by participants in relation to the scheme, from inception to implementation and delivery in primary care practices (NPT categories: communal specification, relational integration, skillset workability). All participants identified a key individual responsible for delivery of the scheme in their practice, typically the practice nurse (NPT: initiation). Significant support from the Public Health Agency and pharmaceutical companies in providing funding and training for nurses was acknowledged as a key to the successful embedding of new processes for asthma self-management (NPT: contextual integration). Further highlighting its importance, participants raised concerns regarding reduction in funding from both of these sources and the impact on the provision of asthma self-management education in primary care. Interaction with patients is integral to the success of the scheme and, while influenced by NPT, fell outside of the framework. Participants highlighted difficulty in getting patients with asthma to attend appointments and discussed strategies around identifying, engaging and understanding patients in order to increase patient involvement. One participant’s reassessment of successfully embedded processes in their practice led us to explore what happens after “normalization”.

Consequences

The NPT assisted in identifying the facilitators and barriers to the implementation of the scheme in general practice in Northern Ireland. Primary care staff identified multi-disciplinary teamwork throughout the lifespan of the scheme as key to its “normalization”, which was now so embedded that concerns were expressed regarding threats to funding and withdrawal of external support. Understanding how practices “normalized” this healthcare could inform further policy on similar initiatives.