Table 3 Theme descriptions and illustrative quotes

The innovation as a motivator to implementation planning

The nature of the innovation

Innovation

Recipients

Context

Facilitation

Participants acknowledged how the content and delivery of training, research evidence presented during training, and evidence-based explanations facilitated a shift towards addressing an unmet need and how by engaging with training activities such as simulated patients, were helpful. It was not only the formal research evidence that had been packaged and presented in the training, but evidence about patient experience, cost and tacit knowledge held by clinicians and managers that unlocked the potential for implementation to occur.

The alignment of the innovation with current policy enabled a way of managing people with OA that supported self-management and moved away from the medical model.

The whole practice approach to training was described as ‘unique’ with participants reflecting on the usual lack of time and opportunity within general practice to attend training sessions with their colleagues. This reflected the social norms amongst each practice group and highlighted how rarely primary care practitioners meet to discuss evidence-based practice or implementation of best evidence.

For the focus group participants, having training staged over three weeks provided an opportunity to practice staff for reflection and feedback (individually and as a team). This facilitated both changes to individual practice and discussion as to how to implement as a practice team. In addition, it enabled nurses to try out elements of the training in practice and identify how elements of the training were transferrable to other elements of care for long-term conditions, i.e. diabetes.

Focus groups

Q1. It is a very different approach, isn’t it, to the, ‘You’ve got a sore knee - ask for an orthopaedic opinion,’ which is the surgical model. And the training has been very much a primary care management model, which is much more appropriate, and I think that’s been very helpful [P1GP2]

Q2. It need not be the GP that then takes that forward, I suppose, with trained nurses or train somebody else…We’ve got a new secretary coming…one of the two secretaries is a lady who has done … some sort of fitness programme or something like that… So, there are quite a lot of people are interested [P3GP1]

Q3. The whole project has been great. It has brought us together on a number of occasions. But often one of us will learn something and then, keep it to yourself and you don’t actually get to, to talk to your partners about it. So, as you all do it at the same time, it’s kind of, unique really, isn’t it? We don’t do that very often…it’s been great you guys coming to talk to us [P3GP1]

Addressing alternative priorities and drivers

Innovation

Recipients

Context

Facilitation

By attending the training component of the innovation, practices were able to identify a previously unmet need for the care and management for people with OA and how this could be improved.

Flexibility was a key feature of the innovation that enabled it to be delivered in more than one way and to fit with local contextual factors and existing organisational systems. A range of contextual factors specific to each practice played a part in influencing implementation. Participants described several examples of individual and practice priorities that influenced implementation and subsequent change. For example, one practice was identified as a financial outlier in the region due to ‘high referrals rates in orthopaedics’. Furthermore, the need and desire to reduce referrals to x-ray and secondary care, meet targets such as Care Quality Commission (CQC), reduce consultations (with orthopaedic surgeons), a positive financial impact, and ability to manage patients with other long-term conditions were cited benefits of the JIGSAW approach.

The characteristics and needs of a practices local population influenced engagement with implementation in some practices. Factors such as an elderly, rural population were motivators to implement the JIGSAW approach whereby patient physical mobility was viewed as important. This, in turn, influenced how some individuals perceived and prioritised the knowledge from the NICE guidance.

Focus groups

Q4. The stuff from Keele, gave us permission and for me it validated - I found that the research, the graphs they put up were very useful…to me, it seemed to be that there’s a different potential and a different narrative now. And, that's endorsed by the research we’ve been given. It just seems a better approach all round…what I hadn’t got was the knowledge that what I was saying was actually evidenced based…that was a big endorsement. I found it very helpful [P1GP2]

Q5. It’s going to reduce – I think it’ll reduce consultations (to secondary care)…it does reduce your other requirements [P3PN2]

Q6. They showed us how to get around these blocking signals that the patients send out, and that’s been really useful because I’ve used it in other respects [diabetes management] as well [P1PN2]

Interviews

Q7. One was, ‘Do you know? It will prompt you to do best care in line with NICE’ and two, ‘When you’ve got a CQC visit coming in...’ – which they were about to have, so the CQC had just announced they were about to start inspecting general practices. They’d never been inspected before, so there were other drivers that give you a bit of a gift… ‘When the CQC come in and say, “How do you know you do Best Care?” For OA, you’ll be able to say, “This template complies with NICE guidance and we can run a report”. ‘You know, it’s up to you’. So, we had a double whammy [P05M]

Maintaining the ‘balance’ within general practice

Context

Innovation

A key consideration for whether a practice would implement the innovation related to the likelihood of the innovation creating more work within the practice at the expense of other conditions and hence disrupting the balance within the practice. This highlighted the pressures faced in general practice and how equipoise is an important consideration in each practice.

Focus groups

Q8. It’s difficult to put it in proportion, I think. You can always improve people’s care, but you can't do it endlessly because you've got, you’ve got other things too, er, it’s general practice, not target practice [P2GP1]

Q9. The only issue I had with, with all of that, outside of it is the proportionality of it all. You know, obviously, you’re focused on this. I mean, you’re a rheumatologist and you’re focused on osteoarthritis, as well. We’re not focused and, shouldn’t be focused. And it’s one of the issues I have with the whole, the way medicine’s going at the moment, in general, but you have to look at keeping everything balanced, because we’re only human and we can only do a certain amount, and when you’ve got to keep 150,000 balls in the air [P2GP1]

Interviews

Q10. If it’s in primary care you’ve got to either fund it or create the funded time for them. If you’re putting something in you’ve got to take something out because they just don’t have the capacity [P11M]

Moving from ‘knowing’ to ‘doing’

N/A

Context

Facilitation

Recipients

The facilitated focus group discussion (conducted as the end of MOSAICS) was found to be a vehicle for KM in which practices ‘action planned’ implementation in the planning stages. The discussion facilitated implementation next steps and helped practices consider ways in which elements of the training could be incorporated and implemented in each practice.

A sense of ownership was described by participants. Characteristics of the practice team, including their attitudes to change and believing in the innovation, were important in optimising implementation. Individual attitudes and characteristics (enthusiasm, motivation) also contributed to driving change. Implementation planning took place collaboratively within the focus groups, however enthusiastic staff members were central to action planning change.

One practice suggested that ongoing discussions regarding implementation may not have occurred in the absence of collaboration. This prompted the Impact Accelerator Unit (IAU) to consider appropriate ‘champions’ to engage with and work with practices outside of the context of the research trial and facilitate implementation.

Champions with clinical, academic, managerial, leadership expertise were recognised as central to implementation. Clinical champions who had played a part in facilitating implementation described ways to approach implementation in a new general practice and identified the importance of understanding the local context factors

Focus groups

Q11. It’s actually really helpful having an external person in, to kind of, guide us through it and make us think about it in perhaps a different way. So, I think we’ve done it better than we would have done [without the facilitated focus group discussion]…definitely (P3GP1)

Q12. I can see it fitting in place with a little bit of education, a little bit of exercise from me in that consultation saying like, ‘In two to three weeks’ time I want you to come and see (practice nurse names) to have a bit of follow up just to make sure you’re doing the exercises correctly and err and they’ll just go through a few other things that you can be maybe doing as a, as the next step.’ That could work quite well really [P1GP1]

Q13. (practice nurse name) and I can have a look at the big pull-out sheet and see if we can section the exercises up and put them on docman…we communicate with the doctors using patient-connected tasks. I mean we could let you know; we could inform the doctors that way, feedback that way if they wanted us to [P1PN1]

Interviews

Q14. You need to know a bit about the practice. So, if you sent me out now into (area) to do JIGSAW in a practice I’d never been – well, I don’t know any of the practices. I would make some definite attempt to find out who worked there, what type of special services they offered, what that – their part of (area) was like, what types of patients were they likely to see before I went in. And who – how many nurses they had, so do a bit of homework [P12GP]

The influence of the primary care context on KM

Non-modifiable factors – restricted resource and capacity

Context

External contextual factors included restricted resource and capacity. Participants discussed the primary care context and how this had changed over time., affecting practice income and their confidence to invest in new staff, services, and resources. The political and financial climate was shown to elicit a reluctance to ‘spend money’ as financial savings was often a high priority for practices.

Capacity for implementation were suggested to be compounded by a recruitment crisis in primary care, a reduced desire to work in general practice among GPs and high staff turnover which made ongoing training (of new staff) a challenge.

Interviews

Q15. They just keep asking more of us and we haven’t got the time to do that within the team we’ve got [P05M]

Q16. The climate is changing rapidly. People are more and more reluctant to put their hands in their own pockets to, to fund a service that’s not attracting any funding [P03GP]

Non-modifiable factors – policy and regulatory environment

Context

Policy and the regulatory environment could affect KM both positively and negatively. Participants described how the increased pressure and demands from policy and regulatory factors (including Care Quality Commission (CQC), Quality and Outcomes Framework (QOF)) have resulted in a ‘target and payment driven’ workforce, and a ‘tick box mentality’ that ‘stifles innovation’. For example, the introduction of the QOF was perceived to influence practice staff views of what a clinical priority was and accentuated the target driven mindset of general practices by driving behaviour and processes to gain financial reward.

However, one practice identified JIGSAW in their CQC inspection and described it as a way of showing how their practice was ‘doing something over and above what others are’ for the quality of musculoskeletal care.

Interviews

Q17. I think for a lot of them they sort of say, well it’s a time factor, you know it’s not top of the priority because it doesn’t qualify for QOF and therefore because it’s not on their plan of target hit list it’s very much down the pecking order [P02C]

Q18. One was, ‘Do you know? It will prompt you to do best care in line with NICE’ and two, ‘When you’ve got a CQC visit coming in...’ – which they were about to have, so the CQC had just announced they were about to start inspecting general practices. They’d never been inspected before, so there were other drivers that give you a bit of a gift… ‘When the CQC come in and say, “How do you know you do Best Care?” For OA, you’ll be able to say, “This template complies with NICE guidance and we can run a report”. ‘You know, it’s up to you’. So, we had a double whammy [P05M]

Non-modifiable factors –service and system design

Context

Recipients

Facilitation

The system design was reported to stymie KM by encouraging working in silos and making cross-boundary working challenging. Working in silos was suggested to limit interactions between key stakeholders and resist information sharing. Practices who worked in isolation were suggested to encourage an inward facing approach. Staff who had dual roles were seen to be helpful in facilitating implementation.

Interviews

Q19. Service design is often just a patchwork of, erm, you know, sort of sticking plasters and, and small changes without anybody stepping back and looking at services holistically…I’m seeing loads (of system design barriers) at the moment, in terms of information sharing across organisations, systems, and processes that support clinicians to work in different environments (P07GP)

Modifiable factors – staffing model

Context

Recipients

The variation of staffing models and structure between practices was identified as having the potential to be both a barrier and an enabler to implementation. A trend for fewer partners in practices and more salaried doctors was described, with several participants suggesting that there was a greater chance of successful implementation in practices that adopted a ‘traditional’ partnership model due to staff feeling a sense of ownership.

Interviews

Q20. I’m most familiar with the partnership model, erm, because it’s historical and I guess I feel most comfortable with that because you’ve got a bunch of people who are equals and are colleagues and although you might find it difficult to convince them, once you’ve got the body of people together, you know that they are all going to carry on thinking in the same way and that their management decisions, once they are joint, will be executed. I think you always get refuseniks in a practice so you might think you’ve got everyone on board but actually, there are one or two that don’t want to do it but I think that’s quite an easy model [P08M]

Q21. If you’re ultimately responsible for your own destiny and your own pay, and your staff, and the welfare of your patients in a small population, I think you’re going to be much more involved in designing that [P03GP]

Modifiable factors – practice culture

Context

Recipients

Participants described how implementation is influenced by several elements of the culture within a general practice such as hierarchy, attitudes towards change, relationships with external partners, communication, leadership and knowledge ‘blockers’. The role of PPG groups in supporting decision making in one general practice was also discussed by several participants.

The presence of hierarchy within a practice was reported to impact the social behaviour and cohesiveness of the group working within it. Variability of power and control for different professional groups was described that impacted on knowledge use and mobilisation in practice.

Interviews

Q22. The nurses in the practice are not allowed any free thinking really, they’re very controlled and they have to do what the practice manager says. Whereas in the other practice, they’re more like nurse practitioners [P12GP]

Q23. Practice nurses have been ignored as a group. They get paid different amounts at different practices, they’re not agenda for change, they’ve no right to CPD, they are employees of a GP practice, so the variation in practice nurse engagement could be huge. We have some practice nurses who didn’t engage at all through to others who absolutely drove it and loved it like it was vocational for them. And you’ve got no leverage over that because the system has left them in a terrible place [P11M]

Modifiable factors – the role of the patient

Recipients

Facilitation

Context

The ability of patients to drive change in primary care was suggested to be due to their knowledge and expertise in their condition along with their preferences for how care should be delivered. This was important to clinical and non-clinical participants who described the ways in which patient groups from academic institutions, patient participant groups in practices and in the community could and did influence implementation.

Interviews

Q24. I think that patient groups are perhaps one of the most powerful resources, in terms of pushing change. I don’t see it as coming from above and I’m, I’m reluctant to say it, I don’t think I’d see it coming from the medical profession as much as it has done in the past or might have done. So, I think it needs to come from somewhere and really, the people with the most vested interests are the patients, - for understandable reasons and I think they’ll drive the agenda more than anybody else [P03GP]

Q25. They’ve played a huge role I would say probably an underutilised one as well again through time, so by connecting with the patient groups, they have become spokespeople so they’re part of the culture change for me. They have been able to articulate that to other patients; you know the change in approach and the reinforcement of understanding about conservative management. And that’s only the start of the journey, you know it needs to go on, but I think they’ve been, for me I felt they were powerful [P11M]

Key determinants of optimal KM

Perceptions and experiences of individuals as mobilisers of knowledge

Facilitation

The value and impact that those who mobilised knowledge had in facilitating implementation of JIGSAW, including the activities undertaken, their skills and attributes both individually and as teams.

Mobilisers of knowledge were reportedly essential for optimising the implementation of JIGSAW; clinicians alone were perceived to lack the capacity in some general practices to drive change for OA considering it was often perceived as a low priority. It was reported that KM may be accelerated by the inclusion of an additional facilitator in primary care.

Interviews

Q26. Having a knowledge mobilisation, someone who can broker that information, can make it concise can separate the wheat from the chaff and can get the salient points across in an easy digestible way is important because as a busy clinician you just simply can’t keep up to date… I think having people whose job is dedicated to supporting and facilitating that knowledge mobilisation that might help the process [P01C]

Q27. I think this is basically about the implementation, is helping people out to transfer from one point, from one stance to the other. And on the way, showing them little gains, just to keep the interest, I guess it’s almost like the salesperson techniques [P13GP]

Q28. I mean the idea of bringing about more change in a practice that’s struggling to make ends meet and trying to fulfil its obligations to its patients, then I think the idea of more change just doesn’t appeal anymore. I think people are exhausted by too many changes and although this, as I say, is a nice project – really neat, small, not a huge workload –but anything extra, even if it’s – you know, licking stamps to put on envelopes, they’d say no [P03GP]

Q29. Professionals will take it as their, it’s their job, it’s part of their job to mobilise knowledge between colleagues, to make sure that you know the fellow GPs in their practice know about this new research so it’s natural to them, but patients aren’t given the knowledge in the first place to be able to do it [P04L]

Q30. I guess it’s giving people, making everybody a patient champion making everybody a person champion, a champion of knowledge, just giving people that information and the encouragement to just go out and talk to others and use their own networks to spread the message wider [P04L]

Knowledge networks

Facilitation

Recipients

Context

The ways in which the affiliation to various networks or groups facilitated the transfer of knowledge across organisational, professional and societal boundaries. Including, confidence; problem-solving to overcome barriers; and, a catalyst to decision making.

Interviews

Q31. Very important and, as I said, that created the groundswell of interest simultaneously with what was happening with the clinicians and if anything, possibly more important, because a lot of people were either brothers, friends, of the initial people I spoke to in that PPG group, you know, might be a sister , a mother, a whoever, they kind of then told them about the service, they went in, spoke to their GP, said I’m really interested in hearing more about this or can you refer me to the new physio service [P01C]

Q32. To have the right people around the table from the beginning from when you’re trying to describe what it is that you want to do because that’s when you’ll pick up what the win, wins are and what the barriers will be [P11M]

Q33. They really don’t want to know what the research is. We find that a lot. What they want to know is what the cost savings is; how it’s going to affect them and their referral rates and how easy is it to implement. So, I think if there was a business case that speaks that language to commissioners that gives them, ‘this is what it can do for your CCG if you implement it. After 12 months, you’ll be here’ – that kind of thing [P09M]

Q34. They (networks) provide you with an opportunity to challenge the way that you have been doing things or your perception of the way that you’re doing things. So whether it’s the orthopaedic surgeons, whether it’s somebody from a different area of the country you know, it’s that exposure to people who are asking you why and also listening to how, you know how people have got to where they’ve got, with their progress and implementation. And then in addition to that, it’s that exposure to yeah okay the evidence is there and case studies are there but actually it’s the human narrative. So, the networks for me is about human contact with other people, it gets far more synapses I think than reading something [P11M]

The workload of KM

Facilitation

Context

Recipients

The workload associated with KM required for successful implementation (which often was too great for clinicians alone to undertake) and the approaches and people required to facilitate this.

Interviews

Q35. Quite often what they want, when there is a necessity for change, they want you to give them a plan every step of the way. And if I reflect back to how successful MOSAICS was, they were supported to make the change every step of the way and everything was funded but you know right down to the setting up the clinics, the training, when the nurse was out, backfilling the nurse, you guys supported them every step of the way. And once you’ve stepped away actually even when we continue to fund the enhanced service, practices from the first fell off of the participation [P11M]