Primary care engagement in health system change: a scoping review of common barriers and effective strategies

Abou Elnour, Amr

General practices’ perspectives on Medicare Locals’ performance are critical lessons for the success of Primary Health Networks.

2015

Australia

General practitioners (19), practice managers (18), practices nurses (15), community pharmacist (1)

To gather front-line staff’s perspectives on Medicare Locals and identify any lessons applicable to Primary Health Networks.

Individual semi-structured interviews

Those MLs that did well continued in an expanded way the work DGP were doing beforehand and made a seamless transition. PHNs will need to build on the strengths of previous PHOs, and create locality structures and processes that maximise the potential for clinical engagement. They will actively guide the dialogue between related microsystems: to achieve this they will have to be clinically led, change management organisations.

Ashman, Ian

Engaging with clinical commissioning: the attitudes of general practitioners in East Lancashire

2014

United Kingdom (England)

General practitioners (85)

To assess levels of engagement with clinical commissioning using a Clinical Commissioning Engagement Scale.

Standardized questionnaire

The findings highlight the potential challenges for CCGs in engaging GPs and in particular responding to perceived problems of capability and capacity. Further research is required to shed light on whether East Lancashire is typical of other CCGs.

Hanlon, Neil

Creating Partnerships to Achieve Health Care Reform: Moving Beyond a Politics of Scale?

2019

Canada

Community actors {managers, frontline providers, general practitioners, municipal leaders, community-based organizations} (65), executives (71)

To illuminate the ways in which competing logics of health care are expressed in and through a rhetoric of scale.

Individual semi-structured interviews

We examine points of tension between providers and administrators engaged in the reform process and show how these are often expressed discursively as a binary opposition involving central and local interests. We offer a critical examination of this politics of scale and seek to unpack claims of hierarchy and power as a means to offer insight into health care reform processes more generally.

Kreindler, Sara A.

The rules of engagement: physician engagement strategies in intergroup contexts

2014

USA

Organizational managers (58), primary care and specialty care physicians (51)

To utilize the social identity approach as a framework for examining how four disparate organizations engaged physicians in change.

Individual and group semi-structured interviews, observation of meetings and engagement events, review of documents

Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members’ identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing “systemness” with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates.

Kreindler, Sara A.

Primary care reform in Manitoba, Canada, 2011–15: Balancing accountability and acceptability

2019

Canada

Provincial and regional decision-makers (35) and primary care physicians (60)

To examine why the balance between accountability and acceptability remained elusive during a period of primary care reform in Manitoba, Canada from 2011–2015.

Individual and group semi-structured interviews, observation of meetings and engagement events, review of documents

Clearly delimited initiatives that directly promoted a specific observable behaviour (accountability) through financial or non-financial support (acceptability) were most successfully implemented. System-wide initiatives with complicated designs (notably a primary care network model that established formal partnership among clinics and regional health authorities) encountered greater difficulties in recruiting and sustaining physician participation. Although such initiatives offered physicians considerable decision-making latitude (acceptability), many physicians questioned the meaningfulness of opportunities for voice within a predetermined structure (accountability). Moreover, policymakers struggled to enhance the acceptability of such initiatives without sacrificing strong accountability mechanisms. Policymakers must carefully consider how acceptability and accountability elements may interact, and design them in such a way as to minimize the risk of mutual interference.

Kreindler, Sara A.

Pushing for partnership: physician engagement and resistance in primary care renewal.

2019

Canada

Family physicians (31), decision-makers (33)

To examine the difficulty faced by healthcare policymakers and managers in engaging family physicians in new models of primary care through a social identity lens.

Individual and group semi-structured interviews, observation of meetings and engagement events, review of documents

Recognizing that the existing physician–system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers’ rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians’ group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group (“bureaucrats”) with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities.

McDermott, Imelda

Achieving integrated care through commissioning of primary care services in the English NHS: A qualitative analysis

2019

United Kingdom (England)

Policymakers (6), Clinical Commissioning Groups (CCGs) general practitioners and managers (42)

To analyse how CCGs have responded to new responsibilities and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems.

Telephone surveys, interviews, observation of meetings

There is a disconnect between locally based primary care and the wider system. One of the major challenges we identified is the lack of knowledge and expertise in the field of primary care at STP level. While primary care commissioning by CCGs seems to be supporting local collaborations between practices, there is some way to go before this is translated into broader integration initiatives across wider footprints.

Pariser, Pauline

Improving System Integration: The Art and Science of Engaging Small Community Practices in Health System Innovation.

2016

Canada

Primary care providers/PCP (30)

To examine the perceived importance of various engagement strategies on initial PCP interest and on subsequent PCP participation in the project.

Standardized questionnaire

Project team acknowledgement that primary care is challenging and new access to patient resources were the most important factors in generating initial interest in SCOPE. The opportunity to improve patient care via integration with other providers was most important in their commitment to participate, and a positive experience with project personnel was most important in their continued engagement. Our experience suggests that such providers respond well to personalized, repeated, and targeted engagement strategies.

Pratt, Rebekah

Identifying Barriers to Collaboration Between Primary Care and Public Health: Experiences at the Local Level

2018

USA

Public health practitioners and administrators (20), primary care organization practitioners and administrators (20)

To identify barriers to collaboration between primary care and public health at the local level in 4 states.

Individual semi-structured interviews

Some barriers to collaboration (e.g., changes to health care billing, demands on provider time) require systems change to overcome, whereas others (e.g., a lack of shared priorities and mutual awareness) could be addressed through educational approaches, without adding resources or making a systemic change. Overcoming these common barriers may lead to more effective collaboration.

Reay, Trish

Getting leopards to change their spots: Co-creating a new professional role identity

2017

Canada

Family physicians (63), other health professionals (26), and managers (73)

To analyze efforts over time to change physicians’ collective professional role identity.

Individual semi-structured interviews, archival government/ AMA/PCN document review

We found that the change in physician professional role identity required significant identity work by a group of actors, but particularly by the managers who had been charged with leading the reform initiative. We contribute to the professional role identity and institutional literatures by showing how others can engage in social interactions with professionals to facilitate the reinterpretation and rearranging of institutional logics that guide collective professional role identity.

Skillman, Megan

Physician Engagement Strategies in Care Coordination: Findings from the Centers for Medicare & Medicaid Services’ Health Care Innovation Awards Program.

2017

USA

Primary care and specialty care physicians (95), program staff/leadership and program partners (577)

To identify roles physicians assumed as part of new health care delivery models and related strategies that facilitated physician engagement across 21 Health Care Innovation Award programs.

Individual and group semi-structured interviews, program observation

We describe engagement strategies derived from a diverse range of programs. Successful programs considered physicians’ values and engagement as components of process and policy, rather than viewing them as exogenous factors affecting innovation adoption. These types of approaches enabled programs to accelerate acceptance of innovations within organizations.

Snadden, David

Engaging primary care physicians in system change - An interpretive qualitative study in a remote and rural health region in Northern British Columbia, Canada

2019

Canada

Family physicians (10), non physician division leads (3), primary care coordinators (18), regional health authority leaders (3)

To describe how physicians were engaged in primary healthcare system change in a remote and rural Canadian health authority.

Individual semi-structured interviews

Physician engagement was recognised as a priority by Northern Health in its efforts to create system change. This was facilitated by the creation of Divisions of Family Practice that provided a structure for dialogue and facilitated a common voice for physicians. Divisions helped to build trust between various groups through allowing constructive conversations to surface and deal with tensions. Local context mattered. Flexibility in working from local priorities was a critical part of developing relationships that facilitated the design and implementation of system reform.

Lack of trust and poor relationships between primary care and decision-makers

“Participants pointed to concerns regarding who was having conversations with whom, and the historical mistrust between professionals and health authorities.” [13].

“Regional actors had kept the frontline out of the early stages of network consultations [and] many community actors still considered the omission of frontline personnel from planning and partnering efforts as a clear indication that the initiative was, ultimately, a “top-down” undertaking.” [14].

“One of the major challenges to integrate care vertically or ‘knitting’ the locally-based primary care plan with regional plans… is the lack of knowledge and expertise in the field of primary care at the [sustainability and transformation partnerships] level.” [18].

Strong professional physician identity

“Directives from ‘above’ to make changes in these daily routines are expected to face resentment and resistance. When considered in connection with ideas of professional autonomy and the sanctity of clinical judgment, frontline personnel and their cultures of practice present potentially substantial barriers to the implementation of these reforms.” [14].

“I think there’s a cohort of people who see it as an opportunity to shape the future and then there’s a cohort of people who think, you know, it’s concerning about the future of general practice.” [18].

“Physicians said that they listened carefully to the [Alberta Medical Association’s] concerns, and they were more leery of full participation in the [Primary Care Network] as a result.” [19].

Clinically irrelevant and complex proposals for change

“Identified barriers to engagement of primary care physicians include limited time and resources, lack of information technology and staff support, and the perception that proposed interventions are either irrelevant or impractical to day-today practice.” [20].

“The slow, bureaucratic nature of decision-making bred frustration and alienation; and the loose, conceptual definition of [My Health Teams] was a source of confusion and even some suspicion.” [21]

Lack of capacity and supports

“Participants cited limited time, capacity, or resources to develop new work or new partnerships in the face of struggling to just “keep the lights on” for current services.” [15].

Building trust and collaborative relationships

“The maintenance of trust could not be assumed… Once trust was developed it was just as important to find some early wins to show progress was being made.” [13].

“Prioritizing policies that encourage aligned planning processes for both primary care and public health could bring partnerships together to explore and identify shared priorities for limited resources. Undertaking shared strategic planning may help partnerships identify and prioritize barriers to address collaboratively” [15].

Targeted engagement strategies as one size does not fit all

“A very personal and iterative approach [was used] to engaging [primary care physicians]. This approach required a high level of oversight by the team and [primary care lead], which is resource intensive and may be challenging to scale to other sites.” [20].

Physician leadership and collective voice

“Leveraging physician champions and establishing innovation-values fit between programs and physicians were critical parts of engagement. In addition to generating a positive innovation climate, these approaches informed innovation policies and procedures as well as how programs tried to prove their value to physicians, often through emphasizing increased workflow efficiency and minimal time investment.” [23].

“Working with structures that were designed to give physicians a collective voice helped build relationships, find common ground, encourage dialogue and enhance continuity.” [13].

Open and intentional communication strategies

“The tensions identified in the interviews were often recalled as hidden and unacknowledged in the interactions between partners… Honest conversations and structures for communication were necessary. Through conscious dialogue, they could surface and work through tensions that developed when changes were made to how services were designed and delivered. These efforts have not been easy or straightforward. They have taken a long period of time, as foundations of commonly agreed-upon and deliberately purposeful actions have required an understanding of others’ contexts.” [13].

“Whereas an earlier narrative included the term ‘rolling-out reform,’ senior administrators later spoke of ‘facilitating reform.’ There was also an effort to brand their new approach as the ‘Northern Health way’.” [14].

Clinically relevant initiatives and straightforward initiatives

“Approaches like this allowed NH and physicians to develop working relationships focused on improving care for the people they served, which allowed tensions to be identified, managed and worked through. Actions were focused on what could be done together to improve patient care, such as the creation of an unattached patient clinic, the development of a family practice clinical teaching unit and actively helping people learn about others’ working contexts.” [13].

“The initiatives most likely to meet their objectives were those in which acceptability elements directly facilitated physicians’ achievement of an outcome for which they were accountable. Such direct, meaningful relatedness between acceptability and accountability was exemplified by initiatives that provided support for a specific, easily observable behaviour, such as electronic medical record adoption or patient attachment.” [21].

Financial incentives

“[Primary care networks] were set up to be attractive to physicians – proposals suggested that family physicians could improve work/life balance, improve quality of care for patients, and receive small financial incentives for engaging in planning processes. Physicians were reimbursed for time spent at meetings, program development and other planning activities, that were otherwise not funded. In addition, money was available to hire a wide range of health professionals.” [19].