21 Realist Review of General Practitioners’ Role in Advancing Practice in Care Homes (Grape Study)

Introduction

Many care home residents have high levels of complex needs and their medical care is the responsibility of the general practitioner (GP) in UK. GPs have multiple roles, including gatekeeper for access to other healthcare services and often play a leadership role in the healthcare team. Our aim is to develop realist programme theories for how GPs interact with care homes to facilitate improvements in care of residents.

Method

Using realist review we aimed to describe “what works” for GPs to be involved in improvements in care of residents. Firstly we carried out a scoping review of UK literature and interviewed GP leaders in order to build programme theory. Secondly iterative literature searches were performed in Medline, Embase, CINAHL, PsycInfo, ASSIA, Scopus and many grey literature databases. This international literature is being used to test and refine programme theories and to explore the range of contexts.

Results

A scoping search identified a small number (n = 5) of recent UK articles (2010–19) that described GP input into quality improvement. To gain insight into context, observational studies (n = 4 in UK and Ireland) were identified which described concerns about workload and resource constraints. To develop initial programme theories, we conducted interviews with 6 GP leaders, where themes of risk and specialism were identified. We are developing the following mechanisms within programme theory: where GP profession have an ownership of the agenda, this encourages GP involvement. In other initiatives, the mechanism may be a trusting relationship between GP and another practitioner, eg pharmacist.

Conclusion

Many reported projects which aim to improve care quality in care homes do not describe how the initiative relates to GP practice. We have identified mechanisms which, when present, may cause GPs to contribute leadership and medical expertise, and thus lead to successful outcomes for residents.

Reducing inequalities in access to health care: developing a toolkit through action research

PROBLEM

Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision.

DESIGN

Locally developed action research projects with an explicit objective of reducing inequalities in access.

SETTING

Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services.

KEY MEASURES FOR IMPROVEMENT

Changes in service provision, increasing attendance rates in targeted groups.

STRATEGIES FOR CHANGE

Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change.

EFFECTS OF CHANGE

A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations.

LESSONS LEARNT

Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A "toolkit" has been developed to support the identification and implementation of appropriate changes.