Family Practice Advance Access originally published online on November 4, 2004
Family Practice 2004 21(6):661-669; doi:10.1093/fampra/cmh614
Family Practice Vol. 21, No. 6 © Oxford University Press 2004, all rights reserved.
Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study
a Department of Social Medicine, University of Bristol, Bristol BS8 2PR, c School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, d London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK and b Stockholm School of Economics in Riga, Strelnieku iela 4a, Riga, LV-1010, Latvia
E-mail: chris.watkins{at}bristol.ac.uk
Received 8 July 2004; Accepted 20 July 2004.
Watkins C, Timm A, Gooberman-Hill R, Harvey I, Haines A and Donovan J. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study. Family Practice 2004; 21: 663–671.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Background. Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts. Educational outreach into practices, alongside other measures, such as audit and feedback, have the potential to enable GP prescribing to become more evidence based. High GP prescribing costs are associated with GPs who see drug company representatives; tend to end consultations with prescriptions; and ‘try out’ new drugs on an ‘ad hoc basis’ and use this as evidence of the drug's effect. An educational intervention called ‘reflective practice’ was developed to meet these and other educational needs. The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice.
Objectives. The study investigated the following: (i) Is it feasible for GPs to attend the sessions included in the educational intervention? (ii) Is the intervention acceptable to the participants and the session facilitators? (iii) What are the barriers to the group educational processes, and how can these be overcome?
Methods. Four practices were recruited in South West England, all of them experiencing problems with prescribing appropriateness and cost. Reflective practice sessions (including a video-taped scenario) were run in each of these practices and qualitative methods were used to explore the complex attitudes and behaviour of the participants. A researcher observed and audio-taped sessions in each practice. At the end of the programme, a sample of doctors and all the facilitators were interviewed about their experiences. The recorded data were transcribed and analysed using standard qualitative methods.
Results. The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions. Elsewhere, doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality. Facilitators came from a broad range of professional backgrounds. While knowledge of prescribed drug management issues was important, the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory. The video-taped scenario was found to be useful to set the scene for the discussion. Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion. Reaching a consensus on management of common conditions was sometimes difficult, partly because the use of the term ‘best buy’ implies economic pressures, rather than benefits to patients, and partly because of the value with which GPs regard the concept of clinical autonomy. ‘Reflective Practice’ appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence.
Conclusion. The study indicates the importance of preparing the practice adequately, including providing protected time for all GPs to attend the educational intervention. Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness. Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized. We have also identified the skill profile of the facilitator role. Our study indicates a need for a clearer understanding of GPs' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment. The intervention is now ripe for further development, perhaps by integrating it with other interventions to change professional behaviour. The improved intervention should then be evaluated in a randomized controlled trial.
Keywords. Costs, educational outreach, GP, prescribing, quality.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Spending on prescribed drugs in primary care in the UK grew by 10% between 2001 and 2002. The Audit Commission1 reports that many Primary Care Trusts (PCTs) are facing a major gap in funding. Although much of this increase in spending can be attributed to the implementation of National Service Frameworks (NSFs) and National Institute of Clinical Excellence (NICE) guidelines, there is concern about the variation in prescribing costs between GPs.2 This variation cannot be accounted for purely in terms of differences in underlying need for health care and is more likely to be because many prescribing decisions in general practice may not depend on recognized pharmacological effects.3,4 Many PCTs face a potentially serious finance and performance risk if issues around costly prescribing are not addressed. Modifying GPs' inappropriate prescribing habits is thus a high priority.
Watkins et al.5,6 have reviewed factors associated with variation in prescribing costs, showing that high prescribing costs are associated with GPs who see pharmaceutical company representatives (‘drug reps’); are reluctant to end a consultation without issuing a prescription; ‘try out’ new drugs on an ‘ad hoc’ basis and use this as evidence of the drugs effect; have inadequate mechanisms for reviewing repeat prescriptions; are not open to criticism of their own prescribing from colleagues; and fail to seek independent evidence of effectiveness before prescribing.
Aims
A prescribing education programme for GPs was designed to take into account these findings. The aim of the study was to assess the feasibility and acceptability of this hitherto unevaluated programme, with a view to improving it (equivalent to phase I of the evaluation of a therapeutic intervention). Once assessed and improved (phase II), the educational intervention should be the subject of a randomized controlled trial (phase III). The study investigated the following: (i) Is it feasible for GPs to attend the programme? (ii) Is the programme acceptable to the participants and the session facilitators? (iii) What barriers occur to the group educational processes, and how can these be overcome?
|
Methods |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Origin and content of the educational intervention
A team (Professor Marie Johnston, CW, AH, IH and Dr Mark Sculpher) from within the MRC Health Services Research Collaboration developed an educational intervention called ‘Reflective Practice’, informed by the research undertaken by Watkins et al.5,6 The intervention draws on ‘the theory of planned behaviour’7 and other studies that have identified the pre-requisites of successful behaviour change in general practice reviewed by Veninga et al.8 (Box 1).
| BOX 1 Pre-requisites for changing behaviour in general practice Awareness that a problem may exist in one's practice Understanding what causes the problem Credibility of the source of information about new ways of managing the problem Open acknowledgement and discussion about individuals' doubts about the new ways of managing the problem Recognition that social force may accelerate acceptance of a new change in practice Identification of barriers to implementation of the new change in practice Identification and implementing ways of overcoming these barriers
|
‘Reflective Practice’ consists of seven sessions designed to take place at monthly intervals, in an individual practice, in the middle of the day. The intervention addresses common problems (see Box 2) presented by patients in general practice which give rise to a wide variation in management responses. The structure of each session of the intervention is shown in Box 3.
| BOX 2 Reflective practice: scenarios piloted (further additional scenarios have been designed) A patient with indigestion. A young man presents with upper abdominal pain, lasting 36 h, after a heavy meal. He drinks 8 units of alcohol a night and smokes 20 cigarettes a day. A patient with cystitis. A young woman presents with urinary frequency and pain on passing urine. She requests a further prescription for ciprofloxacin, which was effective when prescribed by another GP. A patient with depression. A middle aged man presents with depression. He has suffered a previous depressive illness as a student. A patient requests a prescription for HRT. A woman in her late 50s who is new to your practice requests a further prescription for her expensive hormone replacement therapy preparation. She does not want to change her treatment. A patient returns for the result of a cholesterol test. A man in his 50s, whose friend has recently had a heart attack, attends for the result of a cholesterol test which is raised at 6.9 mmo/l. He has no other known risk factors for coronary artery disease. A practice under pressure. A receptionist is faced with angry and dissatisfied patients when a doctor's surgery is running late. The receptionist interrupts a doctor's consultation with a patient who reports a sore throat and demands an antibiotic. A visit from drug rep. A drug rep visits a GP to tell him about a newly available NSAID.
|
| BOX 3 Reflective practice: structure of sessions Video-tape of scenario shown (e.g. a depressed man telling the GP about his symptoms). The scenario is designed to encourage GPs observing the film to engage principally with the patient's problem and not the management response of the doctor on the film. Brainstorm of possible responses. Individuals in the group are invited to suggest possible responses to the scenario, regardless of whether or not they personally would take that action. Personal responses of GPs in the group. Each individual in the group records, in writing, what would be his or her own personal response, selected from the range of responses elicited in stage 2. These responses are placed, anonymously, in a box. Selection of ‘best buy’ response. The personal responses contributed in stage 3 are recorded, anonymously, on a flip chart. The group decides, from these responses, which should become the agreed ‘best buy’ for the practice. If agreement is not reached on a single ‘best buy’, a second ‘best buy’ can be allowed. Identification of barriers to implementation. The group identifies attitudinal issues, skill deficits and organizational barriers to implementation. Means of overcoming the barriers identified. This may involve discussion of consultation strategies, availability of patient handouts, etc. Individuals responsible for overcoming the barriers identified. These may be nurses, secretarial staff as well as doctors. The resources needed for individuals to implement the agreed solution are agreed and the means of providing them identified. Review of effectiveness of implementation. Date fixed for review in 3 months.
|
|
Recruitment of practices |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Clinical Governance Leads and Prescribing Advisers of Primary Care Organizations identified practices in the Health Authority area, from those in the top quintile of adjusted prescribing costs (NIC/ASTROPU)9.
|
Facilitation and set up of sessions |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
At the time the study was designed, a pharmacist member of the Health Authority Prescribing Team regularly visited practices to review their prescribing. It was originally intended that this pharmacist would facilitate the sessions, as a means of enhancing his role. As he was not available at the time of study, six different facilitators from a variety of disciplinary backgrounds (two from commercial and one from academic pharmacy, two from general practice and one research scientist) were recruited to facilitate the sessions. Twenty-one educational sessions were run in four participating practices. A total of 19 GPs and one practice manager took part. To encourage GPs' engagement, all sessions took place over lunchtime, and a sandwich lunch was provided. GPs gained PGEA accreditation for their participation. The aim was to have one facilitator to lead all the sessions in one practice, to provide continuity. However, facilitators were sometimes unavailable at the time when the sessions took place. Continuity was achieved in two of the practices, both led by GPs, one of whom was a partner in the practice where the sessions took place and one who was not. The sessions in the third practice were facilitated by a research pharmacist and a commercial pharmacist, and in the fourth practice by a commercial pharmacist and a research scientist.
|
Data collection |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Qualitative research methods were used to address the research objectives, as they offered the most appropriate way to explore complex attitudes and behaviour.10 An anthropologically trained researcher (AT) observed and audio-taped sessions in each practice. She also took notes of her observations. Facilitators were de-briefed about each session. At the end of the programme, 11 of 19 doctors from all four practices were interviewed about their impressions and experiences of the intervention. The remaining eight doctors either declined or were unavailable for interview at an acceptable time. The majority of these half-hour interviews were audio-taped. One was not taped at the request of the doctor. In addition, two small focus groups were held to gather the views of the various facilitators. One of these groups comprised three of the session facilitators, while the other comprised two of the session facilitators. One was not available.
|
Data analysis |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
All the transcribed data were imported into the qualitative analysis programme QSR NVivo. The primary analysis was performed by AT, using standard constant comparison methods of qualitative research.11 Transcripts were repeatedly read and coded, and themes were identified, which cross-cut all the data sources. CW and RG-H also read and coded a sample of these transcripts. Contents of the sessions were used to inform the interviews and focus groups. Key themes revealed by this analysis are reported below, along with issues of feasibility.
|
Results |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
The study examined the feasibility of the educational intervention, its acceptability and any barriers to the educational process.
Feasibility
Recruitment. Sixty-one practices were informed about the study, through clinical governance and prescribing leads in their PCTs. Of these, 10 expressed an interest but six declined to participate because of the time commitment. (Fig. 1).
|
The low response could be explained because practices were informed about the study at a time when they had heavy organizational demands placed on them, because of the NHS modernization programme. Four practices were recruited. Three of these practices were situated in relatively deprived inner-city areas, while the fourth was in a small satellite town. Two practices offered postgraduate GP training. The numbers of doctors working in each practice ranged from five to 12. All practices were identified as having problems in managing their prescribing costs by the PCT clinical governance leads.
Time constraints and pressure. Table 1 shows the number of sessions run in each practice, the number of doctors who attended each session and, of those who did attend, which were interviewed about the experience. It was difficult to arrange the educational sessions at times when both GPs and facilitators were available. For this reason, the number of sessions run in each practice and also the number of sessions that each GP attended varied between practices. In those practices where it was not possible to run all seven sessions, practices were offered a choice of which sessions they felt most applicable to the problems with prescribing that they were encountering. This was done to foster a sense of ownership, thus increasing their motivation to participate.
|
In the largest practice (practice 4), only three of the 12 partners were able to attend all four sessions run in their practice, and seven partners did not attend any sessions. Of the remaining three practices, at least half of the partners attended all the sessions. The remaining partners were prevented from attendance by holidays, study leave or other in-practice service demands.
Non-attendance was also partly because ‘reflective practice’ was offered as a potential solution to high-cost prescribing. For example, one practice felt that they were under so much pressure about their prescribing budgets that they participated primarily as an attempt to appease their prescribing adviser. This resulted in poor attendance and a reluctance to participate of those who did attend. This defeated the notion of reaching and establishing a consensus that was ‘owned’ by the practice as a whole.
Information overload. During the one-to-one interviews that took place once the intervention had been completed, it emerged that it could be difficult for GPs to match top-down initiatives with everyday practice. The difficulty, which is another form of pressure, was expressed well by one GP who explained in the interview that:
"The trouble is there's so many guidelines coming from everywhere, I think most of us are suffering from information overload. The difficulty is trying to blend what you've been taught with what you feel is right for that patient with what the government or the other guidelines or the ‘best buys’ tell you is best for that patient."
The sense of ‘information overload’ may affect the engagement of practices.
Facilitation. A total of six facilitators administered the intervention. Although knowledge of pharmacy was important, it soon became clear through our observations that facilitation skills and aptitude were at least as important for a positive session as the facilitator having a pharmacist background. As one of the GPs commented when told that her practice had experienced facilitators from different backgrounds: "I think the person's much more important than their background." A facilitators' ability to manage a group successfully was central. The same GP commented that a good facilitator should "be a bit more whipping us into line." We explore this more fully in the discussion.
Acceptability
From the observation of the sessions and subsequent interviews with the GPs, we explored how acceptable ‘Reflective Practice’ was to GPs.
Although there were a few misgivings about some of the superficial elements of the videos (e.g. inappropriate music), doctors saw videos as useful tools for stimulating discussion. For instance, when asked in interview what he thought of the use of video clips, one GP replied:
"Yes, yes, I think the video clip was quite useful. I think a picture is worth a thousand words, definitely. And that definitely applies in these meetings. It sets the scene very nicely. You could try setting the scene by giving them a paragraph to read and fantasize, but each one's fantasy would be different. This way they [the GPs] all see the same clip, they get the same information."
The lack of background material provided in the clips was partly intentional in order to stimulate discussion, but a few GPs complained that insufficient history or background information was provided in the video scenarios.
In each session, after watching the video, participants were asked to work out a ‘best buy’ for each scenario, drawing chiefly on the British National Formulary (BNF) and Clinical Practice as sources of evidence to guide good practice. This process encouraged participants to address the question of cost-effectiveness of different prescribing responses, to apply new evidence for good practice and to address any practice organizational issues that impact on the standard of clinical care. Both GPs and facilitators pointed to the difficulty of reaching consensus on a best buy, especially given limited time during the sessions. Some found the term ‘off-putting’ because of its financial connotations:
"Well the term best buy is just off-putting because it immediately looks at, it implies finance, the financial thing and it just, as a term I didn't think it fitted what we were looking at."
This suggests that some GPs may feel that their management decisions should be based on wider considerations than those of cost-effectiveness.
The educational process
The sessions allowed the group to discuss and thereby share problematic areas that impinged on their clinical decision making and prescribing. Through observation and interviews, the study found that a range of issues influenced the educational process. These included: the impact of group dynamics in sessions; wider group dynamics in practices; and use of evidence sources.
Group dynamics within sessions. The ways in which groups worked together in sessions seemed to be key to their success. For instance, during the educational sessions, group members sometimes seemed to strive to demonstrate their personal high standards of patient care. In the first session with one practice, other members of the group challenged one such statement as unrealistic by poking fun at the speaker and reintroducing real-life considerations.
The structure of each session demanded a firm commitment by the practice to a common management strategy for the condition under discussion. However, we found that GPs were reluctant to do this. This reluctance appeared to arise from a sense of threat to their perceived need for clinical autonomy—a threat motivated by NHS managerial desire to save costs. This impression was not helped by the intervention's use of the term ‘best buy’. One GP described the pressure that his practice was constantly under from the PCT to reduce prescribing costs:
"I've got a little sheet of paper here which is telling me what I should be doing in terms of prescribing, the savings I should be making."
The reluctance of GPs to appear in agreement with one another does not mean that discussions are pointless or ineffective. For example, as we found in an earlier study,12 the process of sharing different management strategies for a particular clinical problem may result in marked changes in prescribing behaviour. This was the case even when explicit management policies were not formulated.
Group dynamics within practices. Responses to the intervention also depended on personal relationships within practices. Some GPs were uncomfortable challenging one another's clinical preferences. For example, in one practice, it emerged that a younger GP was more knowledgeable about current practice than a senior partner. The practice soon decided to discontinue their involvement in the educational intervention, citing ‘time pressures’ and disatisfaction with worksheets as reasons. Another practice found that the lack of consistency between the attitudes to seeing representatives of pharmaceutical companies (‘drug reps’) of older and younger GPs meant that the issue was usually avoided as it was such a ‘bone of contention’. Hence the session that focused on the drug rep was deemed more ‘difficult’ than the others.
One practice used the structured discussions as a training opportunity for GPs new to the practice. They were thus able to enquire about unspoken practice procedures and practice choices (i.e. all that is not necessarily included within practice protocols). This practice also used the intervention for a major review of their practice's clinical and organizational management, occasionally involving the practice manager as well as the GPs. GPs at this practice stated that the programme could be an effective way of involving and influencing those who were at odds with other doctors in a practice.
Most participants stressed the benefits of the intervention for facilitating discussion, which was implicit in the design of the educational intervention. This seemed to counteract the convention of autonomous working practices by GPs, which can lead to professional isolation, even in partnerships. As a GP who was relatively new to one of the practices explained:
"I thought it was really useful for [pause] just to get the practice together and it was useful just to see the thought processes and attitudes towards prescribing from everyone else, because ... although it's a practice everyone works very much as independent practitioners and quite easily spend a whole week going into a little room and coming out again and not really knowing what anyone else does. So that was quite good. It brought the practice together and almost forced you to discuss issues perhaps [we] wouldn't have done otherwise, and if you tried to [do] it would have probably just ended up being too informal maybe. So that was helpful from that point of view, and I think in these days when there is such a pressure on, hmm."
Sources of evidence. Sources of evidence also proved to be an important issue. As a basis for deciding on a ‘best buy’, the groups drew on their own preferred sources of evidence of good management practice. In some groups, if members of the group had not already referred to them, the facilitator introduced the BNF and Clinical Evidence to the group. The intervention highlighted issues about how GPs access sources of evidence to guide their clinical decisions. Most surprising was the reaction to the presence of these texts during the educational sessions. The researcher observed that GPs seized on the books with gusto when the facilitator brought them into view.
Interviews also revealed varied use of evidence sources. For instance, one GP explained that his preferred evidence source was the BNF, and that he used it regularly and had "no problems about opening it in front of patients". In a different practice, one GP explained that although she found Clinical Evidence ‘useful’, and that she had the CD version, she did not have time in consultations to refer to it, and it was the kind of thing she could use at home. One of her colleagues in the same practice kept his copy of Clinical Evidence on a top shelf rather far from reach, and out of use. He explained: "it's one of these things you get sent and sort of goes straight on your bookshelf."
Organizational issues. The intervention also highlighted organizational concerns and brought about change. For instance, one practice was motivated by the intervention to update their hormone replacement therapy (HRT) protocol. In the same practice, one GP described how partners had ‘tightened up’ on visits from pharmaceutical industry representatives, while another said: "We all even thought harder about not seeing drugs reps". Some practices also found that the intervention stimulated discussion of the practice working culture. This was especially apparent in the discussions that followed the video scenario ‘practice under pressure’ (Box 2, scenario 6). In the discussions after the video, three issues emerged: the concern to keep appointment slots available for urgent cases; the need for clear signs at reception; and the availability of patient information leaflets.
Since piloting the intervention, two practices have instituted a regular morning coffee break, which was described in positive terms as a discussion:
"The indigestion [scenario] has come up, and we have a coffee break and quite often discuss clinical things and some comments have come out about that."
The intervention thus encouraged more open discussion of clinical management, achieved, in this practice, through coffee breaks.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
The aims of this qualitative study were to evaluate whether it was feasible to undertake the ‘Reflective Practice’ educational intervention in general practices, whether the process was acceptable to the participants and facilitators and to identify any barriers that occurred in the educational process.
The main barriers to GPs taking part in the process were logistical and attitudinal. Getting GPs together in their practices has also been a major factor in reducing the effects of educational interventions in larger practices in similar educational outreach studies.13 To ensure attendance in the future, the educational sessions need to be protected by the use of a paid locum, in the same way as other practice development work is now being supported. GPs were also unlikely to take part if they felt that the sessions would make them feel unsafe or if they felt that the sessions were yet another ‘top-down’ managerial intervention, where the main intention was to reduce prescribing costs. For instance, there were concerns about ‘information overload’. To deal with these issues, an initial, introductory session of ‘Reflective Practice’ needs to be included, where GPs' experience of previous prescribing management interventions can be aired, where safe ‘rules of engagement’ can be agreed, and the purpose of the ‘reflective practice’ intervention made explicit.
On the basis of the small sample of facilitators, there was no evidence that disciplinary background was the sole key to acceptable facilitation. A certain amount of pharmacological and clinical knowledge was required, as a lack of knowledge about prescription drugs and the pressures inherent in primary care reduced successful group facilitation. However, our observations of sessions indicated that the more positive ones depended on the ability of the facilitator to manage group discussions, especially their ability to create an atmosphere that was non-threatening and supportive. At the same time, good facilitators were able and willing to challenge the group when members colluded with one another to evade potentially contentious issues.
The respect of the group for the facilitator was crucial to the success of the intervention. Facilitators needed to be grounded in a sound knowledge of prescribed medicines, but also needed to have group facilitation skills. The intervention originally was designed with the intention that pharmacists should lead the sessions. However, we found it difficult to recruit pharmacists from the commercial sector with appropriate facilitation skills. The GP facilitators, on the other hand, were experienced in group work, but had difficulty in confronting their peers when encouraging them to reach a consensus on cost-effective management. Postgraduate Deaneries may be a valuable source of suitably skilled facilitators. Another alternative would be to train up a partner to fulfil the role, but difficulties in confronting partners within the practice might reduce his or her effectiveness.
Criticisms of the intervention were often levelled at the design of the intervention rather than its overarching aims. For instance, participants discussed the lack of history in the video scenarios. However, it was probably because these scenarios were neither showcasing ideal consultations nor conclusive in themselves, that participants were motivated to fill in the gaps.
The success of group learning between GPs within a practice depends to a large extent on the quality of relationships within the group. Where individuals feel that their management decisions are under threat from colleagues with whose judgements they are not comfortable, discussion may be abruptly curtailed. For this reason, we feel that it is important, in running the sessions, to preserve the anonymity of the responses of the group initially. Working with work sheets at the beginning of each session means that individual decision making can be examined openly, but not judgementally.
It became evident that the only environment in which this intervention could flourish was one that was safe and interesting but also enticing. Thus, those GPs who suspected that the intervention was an implementation of a top-down (PCT) initiative tended to resist it. Furthermore, ‘Reflective Practice’ allowed participants to state honestly the constraints on their actions by forces outside their control (e.g. government policy). Enabling practices to separate clearly those factors affecting their prescribing decisions that were within and those outside their control made GPs feel that the intervention was supportive.
The notion of consensus in clinical management is one with which many GPs experience difficulty. Many GPs have chosen their career path because of its traditional independence from managerial imperatives, expressed most tangibly in their position as self-employed independent contractors to the NHS. The concept of clinical autonomy is highly valued and it has been argued that in British general practice, prescribing is the principal battleground on which the cause of clinical autonomy is being defended.14 An understanding of what GPs mean by clinical autonomy and how it affects their ability to reach explicit consensus on clinical management decisions is crucial if practice prescribing is to become more cost-effective. Many GPs perceive guidance on cost-effectiveness (such as that offered by NICE) as an intrusion on their professional independence.4 GPs' perceptions of their role, and the threats they perceive to it, need to be understood and addressed if ‘Reflective Practice’ is to achieve its full potential in enabling sustained improvements in cost-effectiveness and consistency of management decisions. ‘Reflective Practice’ appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the BNF and Clinical Evidence, two standard reference books distributed to all NHS GPs.
The problems of raising patients' expectations and consequently GPs' workload by unnecessary prescribing has been described elsewhere.15,16 Developing the skills to offer alternatives to a prescription that are acceptable to the patient is crucial. Discussion of the advantages and disadvantages of these alternatives was a highly valued aspect of ‘reflective practice’. Throughout the sessions, GPs were encouraged to reflect on their own experiences and practice, which may empower them to overcome barriers to change.
|
Conclusions |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
This pilot study of ‘Reflective Practice’ will enable us to improve the content, structure and facilitation of the educational programme in ways that are summarized in Box 4.
| BOX 4 Summary of conclusions of the study Thorough preparation of the practice, prior to engagement, is essential and should include an introductory group session to clarify the ground rules and deal with issues of concern. Each session needs to last 1.5 h, to ensure that all stages in the educational process are adequately covered. To ensure attendance, a locum is required to provide time protected from the demands of patient care while the GPs are involved in the sessions. The benefit to patients of better prescribing is probably a more convincing argument for GPs to change their prescribing behaviour than the concept of ‘best buy’. The British National Formulary and Clinical Evidence have been confirmed as appropriate and acceptable sources of evidence for prescribing decision making. Although a basic understanding of prescribing is necessary for successful group facilitation, an understanding of group dynamics and ability to facilitate group discussion is of greater importance.
|
In view of the evidence from other studies that a single intervention has only a small effect in professional practice, ‘Reflective Practice’ could form part of a multi-faceted intervention to address other issues adversely affecting practice performance (e.g. test ordering and referral). Such an intervention could also include computerized decision support systems to remind GPs, at the time of consultation, of the practice-based prescribing policy developed using ‘reflective practice’. This educational intervention is now ripe for further development and formal evaluation in a randomized controlled trial.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
Funding: This study was supported by grants from the Research and Development Directorate of the South and West NHS Region of the NHS Executive and the MRC Health Services Research Collaboration.
Ethical approval: Not deemed necessary by the chairman of the local ethical committee at the time the study was undertaken, since patients were not involved.
Conflicts of interest: The Department of Social Medicine at the University of Bristol is the lead centre of the MRC Health Services Research Collaboration. The views expressed in this paper do not necessarily reflect the views of either the NHS R&D Executive or the MRC.
|
Acknowledgments |
|---|
We wish to thank all the GPs, practice staff and facilitators who made this study possible. We have strived to preserve their anonymity. We are grateful to Professor Marie Johnston for her help in advising on the design of the educational intervention. We are also grateful to Helen Davies, Catharine Elliott and Sue Williams for their secretarial support.
|
Notes |
|---|
From Veninga et al.8
|
References |
|---|
|
TopAbstractIntroductionMethodsRecruitment of practicesFacilitation and set up...Data collectionData analysisResultsDiscussionConclusionsDeclarationReferences |
|---|
1 Audit Commission. Primary Care Prescribing: A Bulletin for Primary Care Trusts. London: Audit Commission; 2003.
2 Audit Commission. A Prescription for Movement Towards More Rational Prescribing in General Practice. London: Audit Commission; 1996.
3 Schwartz RK, Soumerai SB, Avorn J. Physician motivations for nonscientific drug prescribing. Soc Sci Med 1989; 28: 577–582.[CrossRef][Web of Science][Medline]
4 Weiss M, Fitzpatrick R. Challenges to medicine: the case of prescribing. Sociol Health Illness 1997; 19: 297–327.[CrossRef]
5 Watkins C, Harvey I, Carthy P, Moore L, Robinson E, Brawn P. The attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey. Qual Safety Health Care 2003; 12: 29–34.
6 Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn P. Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional study. Br Med J 2003; 326: 1178–1179.
7 Conner M, Norman P. Predicting Health Behaviour. Buckingham, UK: Open University Press; 1995.
8 Veninga CC, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving drug treatment in general practice. J Clin Epidemiol 2000; 53: 762–772.[CrossRef][Web of Science][Medline]
9 Roberts SJ, Harris CM. Age, sex and temporary resident originated prescribing units (ASTRO PUs): new weightings for analysing prescribing of general practices in England. Br Med J 1993; 307: 485–488.
10 Glaser BG, Strauss AL. The Discovery of Grounded Theory. Chicago: Aldine; 1967.
11 Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Br Med J 1995; 311: 42–45.
12 Watkins CJ, King J. Understanding the barriers to medical audit: insights from the experience of one practice. Audit Trends 1996; 4: 47–52.
13 Nazareth I, Freemantle N, Duggan C, Mason J, Haines A. Evaluation of a complex intervention for changing professional behaviour: the Evidence Based Out Reach (EBOR) Trial. J Health Serv Res Policy 2002; 7: 230–238.
14 Britten N. Prescribing and the defence of clinical autonomy. Sociol Health Illness 2001; 23: 478–496.[CrossRef]
15 Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. Br Med J 1997; 315: 350–352.
16 Marshall T. Reducing unnecessary consultation—a case of NNT? Bandolier 1997; 1–3.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. Petrova, J. Dale, D. Munday, J. Koistinen, S. Agarwal, and R. Lall The role and impact of facilitators in primary care: findings from the implementation of the Gold Standards Framework for palliative care Fam. Pract., October 29, 2009; (2009) cmp066v1. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||