Delegating home visits in general practice through a realist review: Exploring contexts, mechanisms and outcomes

Problem

Recent policies including the NHS long term plan (NHS, 2019) and the new GP contract (BMA, 2019) have re-shaped ways of working in General Practice. In particular, multidisciplinary teams and workforce expansion are seeing the shifting, sharing, mixing and delegation of traditional GP tasks to other staff groups such as community paramedics. One of these tasks is the delegation of patient home visits in order to reduce both GP workload and hospital admissions. Yet the mechanisms of delegation (i.e. how and why delegation occurs) remain opaque and are likely to be highly dependent on a range of contexts. Our synthesis of published evidence aims to explore the ways in which delegation of a home visit relies on context which subsequently affects both patient outcomes and clinical workload within primary care settings.

Approach

Using a realist approach we have synthesised a range of data including qualitative, quantitative and mixed-methods research in addition to grey literature. We have followed the systematic realist review stages advocated by Pawson, making visible the causal explanations of contexts and mechanisms in relation to outcomes regarding delegated home visits through our programme theory.

Findings

Contexts such as the nature of employment, patient conditions and GP perspectives to delegation will be articulated. The impact on patient satisfaction and clinical workload will be discussed in relation to outcomes. Mechanisms such as risk tolerance and trust will be elucidated and the tensions between multi-disciplinary professional identities will be highlighted.

Consequences

Our findings and causal explanations are anticipated to produce review findings that may help with future implementation of delegated home visits and provide guidance to support GP decision-making to delegate home visits to patients (or not).