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«Citation: Dalkin, Sonia (2014) The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What ...»

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Practice D also has an opinion leader present (resource), but this opinion leader is an expert opinion leader, as opposed to a peer. An expert opinion leader exerts influence through their authority and status (Greenhalgh, Robert et al. 2004). The expert opinion leader is a GP at practice D and the Director of the Clinical Commissioning Group. He was a great supporter of the ICP, involved in its design and implementation; his support of the ICP influenced others in his practice (practice D) to also support it.

The literature on innovation diffusion highlights that the ICP’s founder is a ‘champion’. A champion (resource) can aid innovation diffusion as they exert influence on others. Before retiring in 2011, the founder was a GP at practice E.

Thus, the presence of a champion may have resulted in the ICP becoming more embedded at practice E, hence their better outcomes in comparison to other practices. The founder of the ICP meets the criteria to be a champion, described in Chapter 2 (p.40) He hosts PCQV to provide a forum for the health care professionals who deliver the ICP to discuss their unique practice problems (organisational maverick). The founder then works collaboratively with them to formulate autonomous solutions. The PCQVs also allow the founder to feedback to the practices on their performance, thus providing a flexible monitoring system that gives information on resource use such as the commissioned palliative care unit or ACP (organisational buffer). This flexible monitoring system also ensures that innovators properly use the organisation’s resources while still allowing them to act creatively (organisational buffer). He is also a well-respected, long standing GP from the locality (now retired), thus he inherently has organisational, clinical and local knowledge that is valued by others (transformational leader). Finally, he acts as a network facilitator, as he develops cross-functional coalitions within the organisation by regularly hosting multidisciplinary workshops for the full locality including all fourteen practices (network facilitator). Specifically, coalitions have been made between social care and nursing care staff via workshops which addressed issues that affected practice (Greenhalgh, Robert et al. 2004).

Furthermore, the ICP founder worked closely with the management support that was contracted to aid implementation of the ICP.

New systems that have a clear, explicit advantage in either effectiveness or costeffectiveness are more easily accepted and implemented (Greenhalgh, Robert et al.

2004). Thus if health care professionals see no relative advantage (reasoning) in the ICP, they usually will not consider it any further and therefore will not use it (Greenhalgh, Robert et al. 2004). Therefore, seeing the relative advantage is an essential reasoning for ICP adoption. Opinion leaders and champions who provide peer support and advocate the ICP by pushing the palliative care agenda will help other members of their team to see its relative advantage. When asked about the

relative advantage of the ICP, representatives from Practices D and E stated:

Practice D representative: “The ICP ensures good communication around patient care and thus improves patient care. The palliative care pathway helps us provide high quality palliative care. It ensures all aspects of palliative care are addressed and also communicated to Out of Hours care providers.” Practice E representative: “It is a good framework for us, based on sound clinical evidence.” Opinion leaders and champions were identified in high performing practices through field work prior to FG3. However, in this focus group, one of the GPs who works at a high performing practice (practice D) identified correctly that they had an expert opinion leader, confirming the field work theory.

GP4 (FG3): “I think from my point of view (founder) visits were very supportive and helpful but in addition to that, (expert opinion leader) here (at practice D), he was sort of pushing the (advance) care planning agenda as well and motivated us as a practice as well.” The comments from GP4 confirmed that opinion leads played an important role in the embeddedness of the ICP.

Context: Shared nursing team on site which facilitates MDT meetings Nursing care can be shared between practices in the locality. All of the high performing practices share a nursing team with a neighbouring practice. However, despite being shared with another practice, all of the high performing practices have their nursing team on site. This has an impact on the mechanism, as having the nursing team on site will make weekly MDT meetings more achievable.

Furthermore, it increases the likelihood of informal contact and enhances professional relationships within the MDT. MDT meetings are important as they allow for discussions of palliative care and implementation of the ICP. Intraorganisational communication across departmental boundaries within a practice enhances the success of innovation diffusion and therefore enhances embeddedness (Greenhalgh, Robert et al. 2004). The presence of opinion leads will facilitate this by pushing the palliative care agenda at these meetings and helping other health care professionals see the relative advantage of the ICP. Although some of the practices that were not classified as high performing also have their nursing team on site, they do not have other facets of the CMOC such as opinion leaders or champions. Other practices in the locality also have fewer MDT meetings, either monthly or bimonthly.

Both the social care team lead and GP4 highlighted the importance of regular MDT meetings in FG3, confirming the important context of having a shared nursing team on site. GP4 was from one of the previously identified ‘high performing’ practices.

Social care team lead (FG3): “So you’re talking about physical face to face, peer support, sharing information and sort of good practice and having a bit of reflection going on and that sort of pushes it forward and keeps up that enthusiasm around it really. You can see good outcomes for people.” GP4 (FG3): “And I think also the regular MDT meetings, we talk about out palliative care meetings each week and possibly stuff gets highlighted then that wouldn’t necessarily in the course of everyday surgery because it actually is a space to talk about these patients regularly and also I would say that the district nurses are our eyes on the ground really, they see a lot more of the patients on a daily basis than we do as GPs and its good for them to remind us exactly what’s going on regularly regarding these patients.” Discussions in FG3 also highlighted that having the nursing team on site is not only useful due to its facilitation of regular MDT meetings, but also because nurses often prompt GPs to carry out important tasks. This may be due to their more regular contact with patients in the community, as referred to in the quote above from GP4.

GP3 (FG3): “The thing with nurses being on site… (district nurse) was always prodding us (as GPs) to do things.” In summary, health care professionals value regular MDT meetings highly and find these useful in addressing the needs of palliative care patients. Having the nursing team on site can aid regular MDT meetings and nurses can also prompt GPs regularly to carry out important actions. Effective communication across structural boundaries within the organisation enhances the success of implementation and the chances of ICP sustainability (Greenhalgh, Robert et al. 2004). Thus having the nursing team on site is crucial as it facilitates MDT meetings and informal discussions in practice (meeting in the corridor).


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Figure 11: CMOC3 (I), peer support and embeddedness of the ICP.

The mechanism of leadership and peer support in a fertile context (nursing tem on site facilitating regular MDT meetings) has resulted in three practices becoming high performers in terms of intervention use and outcome (preferred place of death).

This CMOC (Figure 11) explains how the ICP is working for the high performing practices. The next CMOC will be its associate, describing how the ICP has not worked as well for one of the other practices in the locality.

CMOC4 (II) – Low peer support and perceived detachment This CMOC is based on evidence from the PCQV with Practice C, a practice that was not performing as well as could be expected. The evaluation of the ICP began in 2011 whilst the ICP began in 2008. This meant that most PCQVs had already been undertaken by the time the evaluation began. However, the PCQVs attended provided crucial insight into some of the practices in the locality.

Outcome: Less use of the palliative care register and other interventions Figure 12 shows that Practice C is increasing its use of the palliative care register.

However, table 7, which displays the number of interventions given to patients, indicates that palliative care registration is still not meaningful to this practice; little further action comes from it.

Figure 12: The number of palliative care registrations in Practice C from 2007 to 2012, using Death Audit data.

Table 7: The number of patients who had interventions in Practice C, using MIQUEST data.

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Despite recent (2011/12) increases in intervention use in practice C, intervention use is still low in comparison to the numbers of palliative care patients registered (see Table 7). This practice’s data is reminiscent of the old palliative care registers that were used in the locality where patients were registered but few interventions were provided.

Mechanism: Lack of communication The PCQVs revealed that Practice C did not have a cohesive team (lack of resource), with the lead palliative care GP having several issues with implementing the ICP. Other staff would not administer or record interventions using the system templates. CQI is based on the premise of a cohesive team who work well together under high quality leadership (Robbins and Finley 1995). Thus the CQI mechanism is unlikely to enhance engagement with the ICP in this circumstance. Practice C also has fewer MDT meetings (monthly) in comparison to the high performing practices (weekly). This gives them less time to provide peer support to one another, an aspect of the MDT meeting that was valued as very important to health care professionals in FG3.

MacMillan Nurse (FG2): “And experience as well you know, you’ve got so many different people with levels of experience and things like that, that you can feed off each other and learn so much from each other, and I think that gets lost doesn’t it when you… (Trails off). Especially in the community because you spend a lot of time on your own, so it’s nice to get together and have those times when you can discuss.” GP1 (FG3): “A very big function of it (MDT meeting) is, is support of members (inaudible) of that (working) family, because every palliative care is different, everyone, everyone is, is different in its own way, it’s unique and challenging. I think that’s a really important output.” GP3 (FG2): “I think support is vitally important to be giving each other and I (inaudible), I can see that going in many different directions. And er, one of the last locums I did here (GP practice), there was a discussion, must have been just before (specialist) left, of a very difficult case which the nurses and the doctors, and most of the support went actually from the district nurses to the two GPs who felt incredibly exposed in the situation, but left the meeting feeling so much more supported, when everybody else had realised the difficult situation they had been in. So I think that the support, seeing it as a whole team was so important.” It was also apparent from the PCQV that practice C did not see the relative advantage of the ICP (reasoning) due to their lack of teamwork. Despite being asked to, they refused to display their palliative care register on a board where all members of the health care team could see it. This would mean that if one GP places a patient on the palliative care register, no other team members would be aware of this registration until the monthly MDT meeting, unless through informal communication. Furthermore, since the MDT meeting is only monthly and will have a large agenda, palliative care may not be discussed in depth due to time restrictions. This contributes to the low numbers of interventions patients receive once put on to the palliative care register. Nurses are often those who carry out preference discussions and ACP and suggest the need for anticipatory medication, whereas GPs are more likely to register patients. This lack of communication (resource) via a palliative care register that all health care professionals can see is having an effect on the interventions provided. To summarise, health care professionals’ reasoning is not being changed to see the relative advantage of the ICP through weak team support and leadership, which leads to less intervention use due to crucial breaks in communication between team members.

Context: Detachment from the ICP and locality At the PCQV the lead GP described feeling detached from the locality in general.

This led to late adoption and slow implementation of templates and backup for administrative purposes. Furthermore, the nursing team are shared but are not on site at Practice C, a crucial context identified previously in CMOC4 (I). The nursing team are actually shared with Practice E (a high performing practice). Thus despite having the same nursing staff, one practice (E) is performing extremely well, administering significantly more interventions and achieving better outcomes (place of death), and one GP practice is not (C).


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Figure 13: CMOC3 (II), low peer support and perceived detachment Practice C is detached from the locality and the ICP (context). They share a nursing team with one of the high performing practices previously identified, but crucially this nursing team is not on site (context). Health care professionals’ reasoning has not been changed to see the relative advantage of the ICP through peer support (resource) from those with significant involvement in palliative care or the ICP (less frequent MDT meetings, no opinion leader or champion present). This has resulted in limited increase in use of ICP interventions such as palliative care registration, preference discussions and LCP use (outcome). Thus, the ICP is less embedded in this practice (outcome), as depicted in Figure 13.

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