We interviewed 23 participants over a four-month period from December 2017 including general practitioners, practice nurses and managers, and program support staff from the PHN. Practice staff were drawn from the four LGAs of Nepean Blue Mountains (Table 2).
Table 2
Participant
|
Number
|
LGA
|
PHN Staff and Contractors (designated below as PHN)
|
5
|
N/A
|
General Practitioners (GP)
|
6
|
Lithgow (1x PN)
Hawkesbury (2x GP, 3x PM, 1x PN)
Penrith (2x PM, 1x PN, 3xGP)
Blue Mountains (3x PM, 1x PN, 1x GP)
|
Practice Nurses (PN)
|
4
|
Practice Managers (PM)
|
8
|
Total Participants
|
23
|
We identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. These themes and the related subthemes are described in Table 3 and detailed below.
Table 3. Thematic structure
Major theme
|
Subtheme
|
Setup and Program Implementation
Patient and Community Education and Promotion
Engaging Patients and Communities in Screening
Practice Enhancement
|
· Staff, contractor and committee roles
· Governance structures
· Funding adequacy and disbursement
· Communication strategies
· Providing program information
· Practice-based support
· Information technology challenges
· Motivation to participate
· General practice screening education for patients
· Suggestions to promote community-based screening education
· Patient empowerment
· General practice strategies in engaging patients in screening
· Challenges for general practice in engaging patients in screening
· Leadership and teamwork
· Practice learning activities
· Quality improvement initiatives
· Program sustainability
|
Setting up and implementing the Cancer Screening Program
Interviewees noted that most program and committee staff, and contractors, had a good understanding of their roles, and expectations were made clear. Most staff felt well supported and knew where they could seek assistance. A strong governance structure was noted with consumer and clinical representation on the program advisory committee. Staff described the program as evidence-based, and similar to other well-evidenced programs. Funding was mostly considered adequate with practice payments described as helpful and an incentive to join the program, even if not covering additional staff time. Distribution of payments to individual GPs rather than to the practice as a whole, was raised as a concern by some interviewees.
Senior management and management here were supporting enough of the program to give us the interest and attention to help it along its way...I appreciated the early meetings which helped embed the [advisory] committee and the work they were doing. PHN 4
…it was quite useful to get financial assistance because it involved time and effort from our practice nurses. GP 1
If the funding comes to the practice, I think it will be better …doctors, when they’re doing their screening - they already get paid by Medicare, or they already charge the patient. PM 2
Communications were prioritised and supported by face to face contact enabling a good understanding of individual practice needs. Program staff at the PHN were considered accessible and supportive, providing personalised assistance. They helped practices set realistic goals and provided information including concerning data extraction.
They began at the beginning at the program, just identifying what numbers the practice had…the size of the practice, and the staff that we have…They certainly do try to personalise it …you can get a goal that’s appropriate for this practice, so that was really good. PN 1
Practice-based support also included online programs, workshops and mentoring by other staff. Practice staff described their learning and skill development and valued improvements to patient care.
…program officers going out and really engaging and understanding what the practices need and having that two-way communication, not just the one-way communication where you’re updating them with changes. PHN 5
I had to learn it first so that I could relay it onto everybody else what is happening and if I didn’t have the PHN here to help me do that, I would be stuck. PM 4
IT support has been very good, they’ve shown us lots of opportunities that we weren’t aware of, to extract data and use that to enhance our recall programs and improve the overall care to our patients. GP 2
Information Technology was a challenge for many practices often requiring tailored support. Practice software was described as inadequate and sometimes provided unreliable or inconsistent data with staff unable to determine which patients needed screening. Valuable time was taken in patient consultations when software was difficult to operate, and not all GPs used computers. Poor connectivity between software programs and problems with data entry meant PHN staff sometimes had to extract data manually.
…in [practice software] there’s no ability for them to build a register. They actually have to do advanced queries, and those advanced queries spit out different results to what [clinical audit tool] spits out. PHN 5
It takes 20 clicks…you have to go into a different section, set the reminders in and a GP’s consult is 15 minutes, the patient might have multiple issues. You are now taking away from the patient. PHN 5
We’ve only got two doctors that use the computers completely...that also makes it difficult for PHN because then …this has to be done manually. PM 8
Interviewees described their motivation for participating. Some noted being motivated to provide high quality patient care through better recall and screening rates. Others were motivated to role-model these activities for GP trainees. For most interviewees, financial incentives were not considered motivating.
The cancer screening recall system wasn’t running smoothly before that, so the patient was missing care of their screening. I knew that if we got the right system in place that would be good for the patient. GP 3
They [PHN] gave us information about the cancer screening rates within our region…they were all very low so that was a big enough incentive to…increase those levels. GP 6
Maintaining motivation was considered paramount and interviewees recommended regular, ongoing PHN support including practice meetings; auditing and frequent feedback. Comparing results with other practices, was seen as a powerful motivator by some practices. Others noted the importance of celebrating successes even small ones. Some interviewees suggested that without continued motivation, screening activities could decline, especially with competing priorities and lack of time to maintain the IT skills required.
It’s helpful to have PHN representation at our meetings just to remind everyone of the support that’s there. GP 4
We are a big practice, we’re a busy practice, and at the moment clinical always comes first so patient care and treatment room duties are higher up my priority list. PN 2
Patient and Community Education and Promotion
Participants described practices providing patient education on screening through brochures and posters in waiting rooms, practice websites, at regular health promotion days and opportunistically during consultations. Some practice staff saw promoting screening as a way to improve knowledge and attitudes, including in the wider community.
Every month we have a health promotion drive – we have mufti days, to draw attention to it. We put the posters up, we encourage, we put pop-ups on our website for patients when they’re doing their online bookings because it goes through our website and just say, “Have you had your faecal occult checked?” whatever the topic happens to be. PM 3
I think it’s just because it’s more in the GPs minds now, so they’re likely to trigger when they’re seeing a patient and have that conversation with them. PM 7
I think if the health professionals, like the doctors and nurses, are talking about screening with them [patients] they're more likely to consider screening, or it might spread culturally to their friends or family, they might talk about screening with their friends or family. PN 3
Community-based workshops and events were also reported as promoting cancer screening. However, it was noted that some population groups such as men and Aboriginal women were hard to reach and requiring tailored education strategies.
… with men [for FOBT], if there was a big football game on you’d get in early to get a ticket or you’d get in early for something that you want. Now, using the same idea, we’re saying get in early to have this test - an earlier diagnosis means better treatment...PHN 3
… gathering the people [Aboriginal women] to come in, … was the really hard part. I had to build a rapport, so I mainly concentrated on trying to get that to happen. The events were easy. It was just getting the rapport, building that…they’d come but it would take a lot of chatting to them. PHN 2
Screening education was regarded as empowering consumers and it was also encouraging for practice staff to see patients engage in cancer screening.
The last three results in some women’s files is their mammogram, their FOBT, and a cervical screening, so they seem to be doing it simultaneously, they’re like, “okay well I’m on the bandwagon I might as well get it all done now”. PN 1
Engaging patients and communities in screening
Cancer screening became a practice priority promoted through team meetings and informal conversations. Systems were developed or improved such as practice registers, recall and reminder systems and practice data collection and audit. Practice staff noted that regular use of these systems encouraged patient awareness and participation.
You can target those people that haven’t been through and you put a warning on that patient’s file saying, “Encourage screening” and “FOBT” or whatever it might be. PN 1
We developed a policy that people will get three reminders for things, so if they’ve got a mobile, they get a text from the practice and then if nothing happens, I write to them, and then they get a phone call... [Practice manager] developed a letter saying you’re due for your cervical screening. PN 4
However, there were challenges with other clinical priorities and similarly other patient priorities. Some patients did not respond to reminders or conversations. Equipment and technological challenges were also reported by GPs and practice staff. They related difficulties accessing bowel screening kits and with communication of results, which often required manual entry into practice software. Practice staff also described the fear and anxiety around cancer screening for some patients.
Sometimes…we’ve got other things as priority and … we need to look at that first…when you’re too busy you just let it go [cancer screening] …PM 2
…with breast screening and mammography, the reports were entered as documents when we got those reports back and therefore they had no coding on them…GP 1
Just public knowledge and fear, of getting the cervical screen done…it’s only a little town that we work in and they’re worried that we might talk about what their screening process involves, or they all talk about the myths, you know of getting a cervical smear done…PN 1
Practice enhancement
Interviewees described increased team work with several practices arranging meetings to keep their staff informed and focused on goals and to share knowledge and expertise. However, there
were also examples of poor engagement within practices which affected confidence and motivation. Some practice leaders did not appear committed to the program and passed responsibility to other staff.
We have practice meetings where we all meet over a lunch time, to update them on what’s happening. So for everyone to be aware of what we want to achieve with the data extraction, they all need to know about it and why we’re doing it. GP 2
It has been really frustrating…it led to quite a few frustrations and initially it felt like, well, why would the staff bother when there’s no direction from the leadership, and it evolved and we decided, we’ll do it ourselves. PM 3
Interviewees noted that the PHN provided learning activities and responsive support throughout the program. Information was available through websites, face to face learning and through a range of resources such as screening Health Pathways and “cheat” sheets for practice staff working with IT. Practice staff described how training improved their efficiency. They became more aware of screening rates and proficient with data entry and cleansing.
I've got a very good liaison officer at the PHN so if I do have any problems I usually just write to her or give her a ring and she will steer me in the right direction. PM 8
The PHN and the Local Health District and one of our doctors have been working a lot on pathways [Health Pathways] which I think is really helpful and the doctors are finding that really useful…because otherwise you’re just sending the patients from pillar to post. PM 1
I think it helped improve her [PN] knowledge of particular programs and probably even the importance of updating the records and keeping all the data, doing a data cleanse …. PM 6
Training was perceived to build staff skills and knowledge, and staff members took on additional roles. Some practice staff felt time constrained with pressing clinical responsibilities while others recommended additional learning activities such as peer to peer workshops and enhanced training for practices and staff with poor IT literacy.
We've got a practice nurse who previously wasn’t doing much practice nurse stuff, was doing more reception work…now we've got her doing more practice nurse things, including looking at [data extraction tool], and doing the audits and extractions from there. GP 6
We still have two GPs that don't use the computer, if they had something like IT support for them the doctors would feel more comfortable to use the computer...PN 3
Practice staff spoke enthusiastically about quality improvements and increased screening rates. Plan-Do-Study-Act (PDSA) cycles were reported to support setting realistic goals and implementation of appropriate activities. Practices refined recall and reminder systems, and developed proficiency in data entry and clinical audit, and in use of data extraction and other practice software. Access to Continuing Professional Development (CPD) points was valued by many GPs interviewed, although not all were aware of this incentive.
This program really enabled those patients to be picked up who are actually dropping out of being screened and may have been dropping out because we weren’t reminding them. GP 1
I think that’s one of the most useful tools [PDSA] actually throughout the program because it did give the admin staff a better guidance, so it did tell us what to do, how to do it, when to do it kind of thing… PM 5
We were already doing screening, but we didn't have the [data extraction tool]. Or even if we did we weren't checking on our screening rates. PN 3
The PHN considered the support they were providing to general practices as crucial in sustaining improvements achieved. Practice staff expressed commitment to continue quality improvement initiatives but some also recommended ongoing PHN support to maintain focus on cancer screening. Most respondents thought data collection and analysis should be performed by the PHN.
I try to make sure that they understand how to do that next time, because it’s important for me that once I leave the program that that becomes a sustainable practice that they are able to implement themselves. PHN 5
Once they get used to it [implementing quality improvement initiatives] they [practice staff] are quite smooth, they are quite good with it, and they are still doing it. GP 5
They [PHN] run the tests, the data extraction…probably once a quarter. I'm pretty happy with it because I don't have time to have it more often than that. PN 3