Twenty-seven participants were involved in focus groups between September 2019 and November 2019. Participants’ individual characteristics are displayed in Table 2. There were 15 patient advocates (5 male, mean age (SD) 57 (19) years) and 12 GPs (6 male, mean age (SD) 53 (12) years). Nearly all participants (93%) resided in major cities with relatively unrestricted access to goods and services (27).
Three themes emerged from our analysis that related to participants’ overall impression on the model and gaps that were identified: i) model represents the ideal of PCC, ii) considering the system and collaborating in care and iii) optimising the general practice environment. We also noted general suggestions from participants to improve the model’s application to the ‘real world’ (Supplementary Table 1). These did not emerge as main themes as they were mentioned in brief but were important to the advancement of the PCC model. Interpretive findings are described below and supported with narrative quotes. Patient advocate data is indicated by PA1-15 and GP data by GP1-12.
Model represents the ideal of PCC
Participants’ ideals of PCC aligned with the components displayed in the model. Providers’ said, “it’s all ideal” (GP2); “I agree with all of it, it’s got everything to it. It’s what I thought it [PCC] was” (GP9). Patient advocates said, “this is a perfect model” (PA3); “In a perfect world, every GP would follow this model” (PA1). However, there was uncertainty to whether it is possible to achieve all components of this model universally in practice. One patient advocate said they had never experienced PCC consistent with the model; “If you showed me a doctor that does this I would go to that doctor” (PA3). Some providers aimed to implement all aspects of the model but indicated that it is not always achievable, “I’m sure this is what most of us would be aiming for” (GP2). One GP suggested that the wording of the model was particularly idealistic, and that it should be changed to be more realistic, “clinicians try to ensure patients have had enough time in consultations” (GP3).
Considering the system and collaborating in care
The complexity of the local health system was reported by both GPs and patient advocates to be a common barrier to PCC. One GP felt a barrier to PCC to be “trying to understand the public system” (GP2). A patient advocate expressed “I’ve had to find [services] myself because doctors didn’t have that knowledge, and because it wasn’t easy to find” (PA7). One GP reflected on an experience regarding care coordination, which was made difficult due to a complex health system, “it could be a year’s wait before he gets reviewed… you’ve got to get him seen faster than that” (GP3).
Cost and remuneration were key considerations of GPs when striving for PCC. One GP felt that personal financial pressures caused by the health system compromised PCC. Similarly, one other GP reported to act against the wishes of a patient if the cost to the health system is too high:
I may refuse to do an MRI [magnetic resonance imaging] if they [patients] insist on it, if I don’t think it’s appropriate, and I think cost is important, we are the gatekeepers (GP6).
Time poor general practice business models, such as “turnstile type medical practices” (GP3); and policy “Medicare is underfunded without doubt for general practice” (GP6) exacerbated time and financial pressure placed on GPs. One solution for patients and GPs to mitigate the complexity of the health system while striving for PCC was to collaborate with other health professionals, peers, and organisations. One GP stated,
It’s very important that we can connect [patients] to helpful resources and allied health professionals. We cannot do everything in one sitting, we are just one person (GP12).
Optimising the general practice environment
Patient advocates viewed the entire general practice environment as an important influence on the extent to which PCC is achieved; “person-centred care starts as you walk in the door!” (PA11). Patient advocates associated the environment with outcomes; “the environment will facilitate the opportunity to have a successful outcome” (PA14). In this context, general practice reception staff were regarded as having a role in PCC because they can “help someone feel at ease… communication, respect and safety start with reception” (PA12). Patient advocates noted that environmental design (e.g. purposeful equipment placement, colours and sounds), general practice culture and reception staff had the potential to promote PCC. One patient advocate (PA14) recounted the experience of a service ‘walk through’. The participant described how valuable his feedback was to the patient-centredness of the service:
…someone painted it, changed the seats, changed the whole format, gave them a little bit of [further] advice, and the next time I went it I was like wow! You could feel the [patient-centred] culture from the moment you got there (PA14).
Conceptualisation and verification of Putting Patients First: A Map for PCC
Putting Patients First: A Map for PCC was conceptualised from the data and is displayed in Figure 2. The map illustrates the integration of new PCC components: considering the system and collaborating in care; and optimising the general practice environment. The verification groups called for the text in the map to make explicit the incentive to deliver PCC, and to be orientated to engage general practice managers, all general practice staff and patients. A purpose statement and ‘what’s in it for me’ statement were added and the six components of PCC were supported with text descriptors as a guide for key stakeholders of PCC in general practice.