Of the 25 GPs interviewed all 18 that expressed an interest in being interviewed following the survey were recruited with a further 7 recruited from convenience sampling [35]. They had a range of clinical experience and were employed at 25 practices across England representing 21 different Clinical Commissioning Groups (CCGs). Two thirds were male (14) and the number of years qualified ranging across participants from 2 to 33. The interviews lasted from between 18 and 59 minutes with an average length of just under 29 minutes. Table 2 summarises participants’ characteristics and practice location by region.
Within the five domains of the CFIR framework we populated each pre-existing construct that was shared by our data with the issues that emerged from our discussions with GPs. The domain, existing construct (with definition) and emerging issues are summarised in Table3 and below we provide a description of each domain, the relevant construct and exemplar quotes for each theme.
I. Intervention characteristics
The characteristics of the intervention describe its’ core components as well as the adjustable elements, structures and systems into which they are implemented [27]. In this context our participants discussed issues within existing constructs relating to the evidence base (for PROMs), the relative advantage they afford, their adaptability, and the complexity and overall quality of their design.
Evidence strength and quality
There is a perceived lack of evidence of the efficacy of PROMs in primary care whether for improving patient satisfaction or outcomes, or on wider service utilisation. For example, one GP described how they would prefer to see some examples of where they were they have been used effectively.
“If there were validated tools which were validated and evidence based to show improved quality of care that would be helpful. Not only that but we were informed of what their value was and given some examples of how they worked… I think in modern medical culture evidence- based medicine is very important, so if there’s something with evidence we can use it.” GP8 (study ID), Male (gender), 28 yrs qualified (years since qualifying as a GP), South East (region)
Relative advantage
GPs described the advantages of using PROMs in comparison to standard care in a number of different areas; for example, PROMs helped provide a framework for shared-decision making.
“It does help direct the discussion regarding future management, especially the mental health patients because it allows them to objectively score how they feel and what’s going on, and allows me to help discuss treatment options with them.” GP12 Male, 4 yrs qualified, West Midlands
Another benefit of using PROMs as part of a consultation was their ability to provide quantitative evidence in support of a particular course of action.
“I think they are quite useful nowadays when patients want reasons for things - I don’t blame patients for that at all, it’s perfectly reasonable - but you’ve got to be able to justify your actions…we should be able to justify our actions, and they are quite useful tools in that.” GP5 Female, 20yrs qualified, North East
One GP remarked on the potential use of PROMs as a robust method of gathering patient views in the evaluation of a new service.
“Yeah, I think every time we think about launching a new community service where you’re effectively offering a service that’s on paper offering ‘comparable quality of care with better access, faster turnaround…’ you’ve got to then seek feedback of outcomes for patients, do they agree with your hypothesis? So I think it very much applies to the launch of new services.” GP17 Male, 4yrs qualified, West Midlands
The use of PROMs is not confined solely to GPs and their value as prompts and support for other clinical staff on the practice team was also described.
“Advanced nurse practitioners and practice nurses perhaps might be more inclined to use them, they might be a bit less confident about their underpinning medical knowledge. They work on commonality although we’ve got some excellent clinicians amongst them, they don’t have the rare and the unusual learning background, so they might be more likely to use them…” GP20 Female, 31yrs qualified, North West
Adaptability
Our group described how the majority of PROMs were completed as paper copies while noting the ease with which they might be transferred to digital platforms. One GP described how being able to capture patient responses electronically would enhance their usability.
“I think they clearly need to be captured in a coded way; they need to be capturable, potentially independent of the consultation. So I don’t think a PROM captured as a result of “now I’ve done your diabetic check are you satisfied with it?”, is necessarily a valid or appropriate way of doing it. I know that there are quite a lot of systems used for texting patients to remind them of their appointments or to ask them to book appointments, and I would think building the PROMs into those platforms so it’s automated and not time consuming to collect them is probably the best way to go.” GP1 Female, 29yrs qualified, South East
Complexity
A number of participants felt that the time it takes to complete, analyse, and usefully integrate the additional sources of information provided by PROMs could impact on their use.
“Yeah, in a pressurised rushing surgery and you’ve only got ten minutes the person usually would need at least 20 minutes to solve their issues, and if you were to include a questionnaire on top of that you would be definitely talking about 30 minutes at least, and you can’t afford to be doing that on a regular basis. You can do it as a one off thing and then you have an idea, but you would be pressurised to just do things quickly...” GP2 Male, 10yrs qualified, North West
Design quality
The lack of an engaging narrative from policymakers or commissioners as to why PROMs were appropriate was described. One GP noted how their branding or presentation could be improved to positively influence attitudes to their uptake.
“…it’s putting it in a lively interesting way that isn’t telling me “this is something I have to do as part of my job”, and it’s not yet another mandatory training that’s just shit awful that I have to sit through for three hours every three years… So making it so that it’s something that people might want to look at, “Look at this! This is interesting!” GP20 Female, 31yrs qualified, North West
II. Outer setting
The outer setting domain relates to the economic, political, and social context within which the organisation sits [27]. Our participants described issues that fall into two constructs previously identified within this domain, patient needs and resources, and the influence of external policy and incentives.
Patient needs and resources
Dependent upon location and the demographic of the local population, the ability of patients to understand the concept of a PROM or its constituent items varied. One GP described the difficulties of using PROMs in populations with poor levels of literacy.
“I do work in a slightly deprived population so we do come across some patients who can’t read or write, or who may not have a good understanding of English, so may not fully understand the questions that are being asked of them.” GP12 Male, 4yrs qualified, West Midlands
Concern was expressed about how the reliability of a PROM might be undermined when completed by patients willing to manipulate the output to serve their own ends.
“I think it would be a waste of time to give a hypochondriac frequent attender a questionnaire about all of their conditions, because then you have to document - sorry for being so honest - but if you have to document your hypochondriac scores for the marks on depression … because people are capable of exaggerating on questionnaires, and if there is the type that is a healthy predisposition to do so then I think that’s another can of worms for us.” GP13 Male, 10yrs qualified, South East
Another reason why it was felt patients might filter their responses was to provide the answers they believe the clinician would prefer.
“…sometimes the patient can fill them in with what they think the clinician might want them to say rather than what they actually feel. So sometimes patients can underplay their symptoms, and equally sometimes patients can overplay their symptoms if there might be some perhaps secondary gain for them in terms of certification from work or whether they want some help with some other part of their care. So I think they can potentially be a bit skewed by that.” GP19 Male, 8yrs qualified, West Midlands
A growing number of patients have multimorbidities [38] and some GPs voiced concerns that using a PROM directed toward a single condition would not produce a reliable result for these patients.
“I think there’s that whole issue of multi-morbidity, and not actually capturing what you want to capture because it’s so hard to tease out what that issue of diagnostic overshadowing what condition is causing what symptom.” GP24 Female, 9yrs qualified, East Anglia
Related to this was the concern expressed for patients whose mental acuity was inhibited by their medical condition affecting their ability to reliably complete a PROM.
“There are certain groups where it can be… it may be a bit more tricky to… I guess patients with cognitive impairment and learning disabilities, and patients with severe mental illness, it can just be a bit more difficult, might just have to be thought through a bit more.” GP3 female, 17yrs qualified, North East
External policy and incentives
The influence of the quality outcomes framework (QOF)[39] on the decision of some GPs to use the PROM Patient Health Questionnaire-9 (PHQ-9) was described.
“So the big one is PHQ-9, it’s pushed very hard and for example with people with chronic diseases as well it flags up in the QOF box on EMIS. But in reality it’s irrelevant to assisting you that much in terms of referral and management, so there’s no point in doing it.” GP18 Male, 2yrs qualified, West Midlands
III. Inner Setting
The inner setting relates to the structural characteristics of an organisation and its culture and capacity for change[27]. Our participants described issues within two CFIR constructs; the impact of the organisational climate around implementation, and the readiness of their organisation for change.
Implementation climate
Our participants described how there was little impetus for changing existing ways of working to incorporate PROMs. A number of those we spoke to felt their training meant they could gather the same information without using PROMs which could actually impede patient-focussed conversations.
“I think there’s a role and a value to having a PROM but I don’t think it replaces a face to face discussion with patients.” GP12 male, 4yrs qualified, West Midlands
“Perhaps it a gap in my practice, I don’t know, but personally I find that seeing a patient with as few distractions I suppose as possible to get… sometimes I ask them to make a diary of their symptoms or something like that but that would be their own interpretation of what I have asked them to do rather than somebody else’s interpretation of what they be expected to feel, or might put ideas into their head a little bit.” GP19 Male, 8yrs qualified, West Midlands
Participants described the relatively low priority of implementing PROMs into everyday practice. One GP noted that current processes already produce an abundance of patient data and there was little incentive to collect more.
“…when you talk about the frailer ones, the ones who have all the diseases, all the medicines, and they’re common as well, they are not… your priority with them is not filling out a PROM it’s about trying to actually get them functionally better, and trying to… and not be bamboozling them with lots of extra questions. It’s examining them and looking at what you actually need to do to improve their care rather than just trying to capture how bad they are right now… GP24 Female, 9yrs qualified, East Anglia
“You have to think very hard about taking too much routine data. You need to be selective, it needs to be really useful, it needs to be available for an individual...” GP22 Male, 30yrs qualified, North West
The variable degree to which PROMs were successfully integrated into existing systems was discussed. One GP described issues with their incorporation into their clinical Information Technology system.
“So we do have some which are integrated into the system, but they are not quite integrated enough to be user friendly … you have to input the data and then the score is added up wrong because the template is set up wrong, so you end up having to override it and do it yourself anyway which makes it a bit of a waste of time it being integrated…” GP19 Male, 8yrs qualified, West Midlands
Readiness for implementation
Participants described how they were unaware of which PROMS to access given a certain set of circumstances. For example one GP felt it difficult to remain aware of which were available even within a single condition and bemoaned the absence of relevant training.
“I think that forever more are appearing, COPD have got a whole range of them now as well, about patient’s feeling of breathlessness and stuff. I think the difficulty is remembering which disease now has one … I have never been trained; perhaps I am doing it wrong. I stick the piece of paper in front of the patient and they look at it and ask them if they need any help. That’s probably a terrible way of doing it, I don’t know. If we need training I don’t know when we’re going to get it, but probably I am terrible at it, I don’t know.” GP5 Female, 20yrs qualified, North East
IV. Characteristics of individuals
The individuals involved in the implementation have their own agency and relationships with each other and the intervention depending upon their unique characteristics [27]. The impact of the variation in knowledge and beliefs between multiple practitioners was apparent.
Knowledge and beliefs
Differences were noted between providers as to the perceived role of PROMs with a number of those we spoke to described their worth only as a research tool.
“I think PROMs tend to… the thing with a lot of PROMs they tend to be very useful in research, and not so useful in actual daily practice, and that’s where… if you’re going to use a PROM it needs to streamline your service not add more time to it. GP18 Male 2yrs qualified, West Midlands
Others felt that PROMs had the potential to make a positive contribution to patient experience and outcome if used correctly.
“Ultimately I think they could be really useful in many situations but sadly I think the way they are used at the moment probably doesn’t maximise their benefit and actually they are probably seen as more of a nuisance than a value really in most ways that they are used currently. So yeah I think there’s work to be done.” GP23 Female, 8yrs qualified, North East
V. Process
The process of implementation involves the development of an appropriate plan and the engagement of organisations and individuals in the process of change [27]. The GPs we spoke to described issues with both the strategic planning of the utilisation of PROMs and the management of staff in their implementation.
Planning
Participants described how the introduction of PROMs into their practice occurred on an ad hoc basis, for example due to the attendance of a course to comply with the requirements of continual professional development.
“I tend to find if I’ve been on a course and they will tell me about a PROM I will use it for a few days and then I’ll forget about it, but that’s probably what I’ll tend to do, if I’m on a course and they just share a PDF of it I’ll give it a try and see if I like it.” GP15 Male, 17yrs qualified, North West
Another described how their use of a PROM would be dependent upon multiple recommendations from a variety of uncoordinated sources.
“… I am unlikely to go and start using some new coeliac disease PROM when I have just been to a talk from a private gastroenterologist or something like that. I am more likely to use something that is appearing to me in lots of different areas of my CPD or medical education. So I might see a paper about it, and then I might hear a colleague talking about it, and then I might see something on GP Notebook or something like that. So you’re getting over exposed to it, and then try it out and see how well it resonates, and how useful it is and how quick and easy to remember it is.” GP24 Female, 9yrs qualified, East Anglia
Engagement
The degree to which relevant individuals are engaged in the process of implementation can affect its success[27]. For example, GPs were resistant to the use of PROMs when introduced as a mandatory aspect of the referral pathway.
“I think a lot of GP colleagues my feeling is that they don’t like anything compulsory, so when the CCG said you need to fill in this score otherwise we will reject the referral I’ll tell you that didn’t go down very well with everyone.“ GP13 Male, 10yrs qualified, South East
Another GP noted that robust objective evidence of their efficacy was more persuasive than any subjective recommendation from a CCG that may have contrasting priorities to practicing clinicians.
“If the CCG say we had to use it… then we would use it, but just because the CCG says doesn’t put [my] trust in it really because they do it for political reasons and bureaucratic reasons, not necessarily medical reasons. For me I am quite evidence based personally, and if someone was to show me… I’m the outlier and most GPs love PROMs and I would actually be thinking ‘hang on I’m the outlier here, actually maybe I’ll just get more on board’. If there was a study saying this particular PROM if they said PHQ-9 shortened a ten minute consultation down to five minutes, improves on patient outcomes, reduces re-attendance rates, improve compliance to medications, then I would say right we’ve got to get on board and do that.” GP18 Male, 2yrs qualified, West Midlands