Strategies supporting sustainable prescribing safety improvement interventions in English primary care: a qualitative study

Abstract

BackgroundWhilst the use of prescribing safety indicators (PSI) can reduce potentially hazardous prescribing, there is a need to identify actionable strategies for the successful implementation and sustainable delivery of PSI-based interventions in general practice.AimTo identify strategies for the successful implementation and sustainable use of PSI-based interventions in routine primary care.Design & settingQualitative study in primary care settings across England.MethodAnchoring on a complex pharmacist-led IT-based intervention (PINCER) and clinical decision support (CDS) for prescribing and medicines management, we conducted a qualitative study using sequential, multiple methods which comprised of documentary analysis, semi-structured interviews and online workshops to identify challenges and possible solutions to the longer-term sustainability of PINCER and CDS. Thematic analysis was used for the documentary analysis and stakeholder workshops, whilst template analysis was used for the semi-structured interviews. Findings across the three methods were synthesised using the RE-AIM framework.ResultsWe analysed 48 documents, undertook 27 interviews and two workshops involving 20 participants. Five main issues were identified, which aligned with the adoption and maintenance dimensions of RE-AIM: fitting into current context (adoption); engaging hearts and minds (maintenance); building resilience (maintenance); achieving engagement with secondary care (maintenance); and emphasising complementarity (maintenance).ConclusionsExtending ownership of prescribing safety beyond primary care-based pharmacists and achieving greater alignment between general practice and hospital prescribing safety initiatives is fundamental to achieve sustained impact of PSI-based interventions in primary care.

Understanding factors influencing uptake and sustainable use of the PINCER intervention at scale: A qualitative evaluation using Normalisation Process Theory

“…These findings support other work [ 17 ] in highlighting the importance of intervention alignment with stakeholder values and local and national agendas, taking a team approach and emphasising how different interventions can be used in a complementary rather than interchangeable manner. Overall, the findings of this study could form the basis of a framework or checklist for the successful implementation and sustainable use for other primary care interventions.…”

“…Delivering new practices or more complex care normally requires co-ordination, collaboration and delegation of tasks both across and within organisations, which if done without appropriate consideration or planning can become fragmented and less effective [ 44 ]. Of relevance to this, the recent evaluation of PSI based interventions, including PINCER, highlighted that taking a team approach across the health-care system and professions was deemed important by relevant stakeholders [ 17 ]. In regards to within organisation approaches, in this study there was a lack of inclusivity or not taking a more practice-wide approach observed amongst some of the participating organisations.…”

“…Intervention effectiveness, acceptability and feasibility of implementing PINCER in different settings as well as contextual factors that could impact on its use and effects were also assessed from the scaling up phase which was conducted across one region of England in which one of the counties from the trial is located [ 13 ]. More recent work aimed to identify overarching strategies that could support implementation and sustainable use of prescribing safety indicator based interventions, which although included PINCER was not intervention specific [ 17 ]. Informed by the Normalisation Process Theory (NPT) [ 18 ], the study reported in this paper investigated longitudinally how PINCER was understood and operationalised during the national roll-out phase with the aim of expanding on the aforementioned evaluations and identify underpinning factors that could help facilitate the success of implementation and sustainable use across different primary care settings on a national level.…”

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability

“…Overall, participants' perceptions on the concept of PINCER were positive although there was some scepticism surrounding the possibility of it being a cost-cutting tool, which is in contrast to the perspectives of health-care professionals who reportedly consider patient safety aspects of an intervention to be more important and appealing than its cost-cutting potential [22]. A lack of understanding on the role and expertise of general practice pharmacists was PLOS ONE identified, with those who had more knowledge on this advocating that awareness of general practice pharmacists' role and capabilities should be raised amongst patients.…”

“…Process evaluations of PINCER thus far have explored stakeholder and staff perspectives on the intervention, contextual factors that could influence its use and effectiveness [16,19,20] and potential cost-effectiveness [21]. More recent work, including an unpublished evaluation with staff and stakeholders, has also proposed strategies that could be used to support optimal and sustainable use of PINCER across different primary care settings [22] however, there has been limited work done to explore patients' opinions on the use of PINCER in primary care.…”