GPs' involvement to improve care quality in care homes in the UK: a realist review

Notes

Permissions

Chapter 1 Background

Parts of this chapter are reproduced with permission from Gordon et al. 1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Chapter 2 Methods

Realist review is a theory-driven approach to evidence review often used to address complex issues of health service delivery. Realist approaches recognise that context always influences a social programme’s outcomes. By testing different plausible explanations of how particular contexts trigger responses or mechanisms to achieve (or not) certain outcomes, it provides an evidence-based narrative of what is most likely to work, how and when. 31,32 Realist theories are often expressed as a statement of (1) context (i.e. social and environmental factors), (2) mechanism (i.e. the causal powers that lead to patterns of behaviour or choices) and (3) outcome (i.e. the change in process, relationships or empirical measure). 33 Several contexts–mechanisms–outcomes (CMOs) may be linked together into a programme theory that describes the key attributes and or activities of an intervention necessary for it to achieve the desired outcomes. The realist review method is iterative and revisits, reinterprets and tests the evidence against the programme theory as it evolves. These core concepts are further described in Box 1.

Here, the social programme that we are describing relates to the role played by GPs, or primary care doctors, in service development, implementation of evidence and improvement in care homes. The scope of the project was purposefully broad to explore how GPs engage with a range of improvement approaches and topic areas. Although we include QI, we acknowledge that this term is used differently and, therefore, have not constrained our search to this term. The diversity of QI initiatives, together with diversity of GPs and care homes, prompted the project team to select realist review because the method is capable of synthesising complex systems. Furthermore, our review proceeded with a primary search followed by secondary iterative searches to enable flexibility and refinement of scope and to enable greater focus on emergent themes.

Steps of the realist review

The review followed a four-step approach:

1. locating existing theories and developing putative programme theories (i.e. if/then statements)

2. searching for evidence

3. extracting and organising data

4. synthesising the evidence and drawing conclusions.

Although described as discrete, these steps were an iterative approach that moved between the literature, stakeholder interviews and our Context Expert Group to develop a robust and evidenced programme theory that addressed the aims and objectives. This is summarised in Figure 1.

FIGURE 1.

Flow diagram summarising iterative review process.

Step 1: locating existing theories

This initial step explored what has worked well when GPs work with care homes, how the different elements of GP working are thought to have made this happen and what is needed to be in place for it to occur. The scope included service development, delivery and improvement in care homes. Our starting point was the theories developed within two realist studies: the Optimal study9,10 and the PEACH study. 12,37 These studies had identified key principles of working across health and social care, with the former focusing on design, provision and delivery of statutory services and the latter focusing on bottom-up QI initiatives driven by practitioners in response to the needs of residents. Both studies9,10,12,37 identified the issues of how GPs work with care homes to be a particular issue for further study. Examples from the Optimal study9,10 included how incentive payments to GPs could have both anticipated and unanticipated effects on practice, depending on how GPs integrated specified activities into existing models of working. The PEACH study,12,37 meanwhile, identified GPs as prominent leaders within primary and community health care who could influence the success or failure of an initiative by virtue of their level of engagement and the ‘permission’ they gave, either implicitly or explicitly, for improvement to proceed. The reference lists from these studies, alongside initial scoping reviews of the literature, using broad search terms around care homes and general practice, enabled us to structure a series of theory-gleaning interviews with GP leaders and practitioners. We describe the ways in which these findings led to the stakeholder interviews in Chapter 3 and we provide a schedule for these interviews in Appendix 1 as a way of making transparent how previous research informed and shaped interviews. Interviews, in turn, informed further scoping reviews (see Figure 1). This work enabled us to iterate towards a definitive search strategy for step 2.

For the interviews, we recruited a purposive sample of GPs through professional networks from different parts of England. Participants had experience of QI work in care homes or had senior leadership roles. Participants were given participant information sheets and asked to give written consent. Interviews were semistructured and took place by telephone or videoconference. Themes for the interview schedule were developed from the scoping literature and discussions within the project team (see Appendix 1). Themes included the range of approaches used by GPs working with care homes to achieve health-care improvement. In addition, interviewees were asked about the extent to which the achievement of improvement objectives were influenced by the support and involvement of GPs, and the ways in which this operated through engagement with other professional groups. We asked how the GP contribution was affected by the presence or absence of other care professionals. Furthermore, we explored aspects of context identified in the literature as important for QI and improved resident outcomes. Interviews were transcribed and coded in qualitative data analysis software (NVivo 12; QSR International, Warrington, UK). From analyses of GP interviews, and scoping literature, as well as the expert knowledge of the project team, we built an initial programme theory that shaped our literature searches during step 2.

Step 2: searching for evidence

We used our initial programme theories (from the literature scoping and theory-gleaning interviews with GPs) to structure the evidence search terms and review parameters. There were specific topics that had been the focus of improvement interventions in care homes and were particularly relevant to the role of the GPs, namely medication optimisation through medication review and end-of-life care. Our stakeholder interviews and Context Expert Group suggested that the ways in which GPs worked with and for QI in these areas could provide case studies to inform more general programme theories about the how GPs participate in improvement in care homes. Discussions with the project team about the context raised the concern that international literature may not be informative because of the distinct context of the GP within the NHS in UK. Therefore, searches were limited to UK literature.

Three searches, in addition to citation searches, were conducted across five academic databases [MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and PsycInfo^® (American Psychological Association, Washington, DC, USA)] and also the Cochrane Library. In consultation with information specialists, we decided to use Web of Science rather than the Applied Social Sciences Index and Abstracts (ASSIA), as had been proposed in the protocol,1 because initial searches indicated that the social science focus of ASSIA would result in relatively low yield. In summary, the searches were as follows:

• primary search – GP and care homes, limited to UK, 2000 to April 2020 (see Appendix 2)

• secondary search – medication review or pharmacy optimisation and care homes (but not specifying GP), limited to UK, 2010 to April 2020

• secondary search – end-of-life care or palliative care and care homes (but not specifying GP), limited to UK, 2010 to April 2020

• citation searches of key authors and key articles.

We chose different date ranges for these searches based on criteria of relevance and rigour. 36 Relevance relates to whether or not data within a document can contribute to theory building and/or testing, and rigour describes the extent to which the methods used to generate the relevant data are credible and trustworthy. We found that, when focusing on GPs and care homes, much of the literature before 2000 did not describe QI and was less relevant to current models of clinical practice because of changes in how primary care has been configured in relation to care homes over the intervening period. Arrangements such as GPs charging retainer fees to care homes and a focus on care delivery at the individual resident level were prevalent in papers from the early 2000s. 38–40 These arrangements were less of a focus from 2010 onwards, when articles shifted to focus on structured interaction between GPs and care homes at an organisational level, and on contractual arrangements. In topic-specific searches, we did not specify ‘GP’ and searches were intentionally broader; however, screening to investigate GP involvement in each article was more time-consuming and, therefore, we focused on more recent literature (from 2010 to April 2020) that would be more reflective of current contexts.

As improvement and other types of development work undertaken in care homes are frequently discussed outside academic literature, we searched for grey literature using web searches (Google; Google Inc., Mountain View, CA, USA) to look for outputs from royal colleges, specialist societies and other professional bodies, such as the British Medical Association (including local medical councils), the National Association of Primary Care (London, UK) and the Social Care Institute of Excellence (London, UK). Websites of charities, such as the Nuffield Foundation (London, UK) and the Health Foundation (London, UK), were also searched. We made enquiries via the Health Foundation ‘Q Community’, which is a national network of practitioners, leaders, managers and academics that is focused on health-care improvement, and through the community geriatrics and general practice special interest groups of the British Geriatrics Society (London, UK) to further source relevant grey literature.

Step 3: extracting and organising data

The initial programme theories informed the design of a bespoke data extraction tool that included details about the study type, the intervention, the improvement approach and the number of care homes, staff, residents and GPs (see Appendix 4).

Evidence reviewed included a description of the involvement of GPs in the implementation of a new service or service model, or evidence that described an intervention to improve the quality of existing health care. Articles were excluded if they described routine health-care provision outside the context of service development, implementation or improvement, if they described social care in isolation from health care or if the role of GPs was not explicitly considered. Screening at all stages of the inclusion/exclusion steps was conducted by one reviewer (NHC). Relevant data from studies were extracted onto a bespoke data extraction form by two reviewers (NHC and RD). The list of included/excluded articles, the text of included articles and how these articles were used to populate the data extraction form, were reviewed and discussed by all team members at regular project meetings.

Qualitative synthesis was undertaken in qualitative analysis software (NVivo 12). All interview transcripts, selected articles and selected grey literature were imported into the software. Nodes were created based on the putative programme theories described in step 2.

Step 4: synthesising the evidence and drawing conclusions

In step 4, analysis focused on how the evidence built on, refuted or provided alternative explanations for key aspects of GP work in care homes, where outcomes may be at the level of the organisation or the resident.

We looked for outcomes in articles that mapped to our outcomes in our emergent CMO patterns. These outcomes largely related to improved partnership working or improved co-ordination of care processes. For each CMO, we visited our collated literature, first to look for evidence that supported our theory and then for evidence that contradicted or required us to adjust it. We focused on CMOs in which there was evidence from more than one paper that there was some replication of the way in which contexts triggered mechanisms to achieve outcomes (i.e. demi-regularities).

Chapter 3 Findings

Step 2: search strategy, PRISMA flow diagram and included articles

We developed an iterative search strategy based on the putative programme theories developed in step 1 to capture the GP role in improvements under these headings to provide case studies that would inform programme theory development. We have summarised this search strategy in Chapter 2 and in Appendix 2.

A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram is shown in Figure 2. The primary search for UK articles including care homes and GPs (with a publication date range of 2000 to April 2020) retrieved 431 articles (see Appendix 3, Table 8). Secondary iterative searches were performed for end-of-life care and medication review (both with care homes, but GP was not specified in search terms), with the aim of identifying articles that may have been missed by the primary search. These searches (with a publication date range of 2010 to April 2020) retrieved 101 and 156 articles, respectively (see Appendix 3, Tables 9 and 10). Citation searches were conducted, as well as hand-searches of selected journals and follow-up of recommendations from the project team and interview participants. After removing duplicates and screening, 73 articles were included in a full-text screen. Twenty-eight articles were excluded following the screen of the full text because the studies were observational (e.g. qualitative, cross-sectional survey or database analyses), rather than studying an intervention, QI or other type of change management process. Fifteen articles were excluded because they were found to not describe GP involvement (e.g. GP records may have been used to identify participants or extract data as an outcome, but the GP was not specifically involved in the intervention). Thirty articles were finally selected for data extraction and synthesis, as listed in Table 2.

FIGURE 2.

A PRISMA flow diagram.

TABLE 2 - Articles included in the review following iterative searches, arranged by programme theory and study keyword (peer-reviewed and grey literature reports, all based in the UK)

CMHT, Community Mental Health Team; EVIDEM-EoL, Evidence-based Interventions in Dementia–End-of-Life; GFS-CH, Gold Standard Framework for Care Homes; NA, not assigned; ND, no date; WHELD, Wellbeing and Health for People with Dementia.

Programme theory	Study keyword	Date	First author surname	Title	Journal	Study type	Key findings	Reference
1	New care models	2018	Elvey	Implementing new care models: learning from the Greater Manchester demonstrator pilot experience	BMC Family Practice	Qualitative observation of pilot projects	Challenges identified were trust to enable collaboration, especially relating to data-sharing	65
1	Palliative care	2016	Iliffe	Improving palliative care in selected settings in England using quality indicators: a realist evaluation	BMC Palliative Care	Realist evaluation	GPs could not be recruited. Care homes could not be retained. The quality indicators set were not motivating for GPs or care homes (they may have been too specialist)	66
1	EVIDEM-EoL	2016	Amador	Evaluation of an organisational intervention to promote integrated working between health services and care homes in the delivery of end-of-life care for people with dementia: understanding the change process using a social identity approach	International Journal of Integrated Care	Qualitative appreciative inquiry	The intervention supported integrated working due to shared goals and recognition of different expertise Bottom-up process of implementing context-specific practice innovations and tools The approach accommodates diversity	67
1	End-of-life care	2011	Evans	Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice-based audit	Journal of Evaluation in Clinical Practice	QI: audit	Initial audit showed that 55% of deaths occurred in the care home, whereas this had increased to 75.5% in the second audit. GP visits to nursing home patients increased by 10.3%, but visits to residential home patients decreased by 5.4%. There was a 43% reduction in emergency admissions with a 45% decrease in deaths in hospital	68
1	Vanguard	2018	Stocker	Care home services at the vanguard: a qualitative study exploring stakeholder views on the development and evaluation of novel, integrated approaches to enhancing healthcare in care homes	BMJ Open	Qualitative study of planned implementation	There was a moral imperative for proposed change to services. However, integrated working was not clearly understood. There was a perception of the programme being ‘top-down’ and imposed by the health service. Trust within the system was valued	69
1	Antipsychotic de-prescribing	2016	Szczepura	Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period	BMJ Open	Quantitative retrospective analysis	Prescribing rates did not change following implementation of the policy, nor was there a shift to second-generation antipsychotics. Duration of prescribing was excessive in 69.7% of cases. There was an association between high prescribing and deprivation of the area of the care home. There was an association between low prescribing and single general practice	70
1	Medication review	2011	Patterson	A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland study): a cost-effectiveness analysis	Journal of the American Geriatrics Society	Cluster randomised controlled trial	Psychoactive drugs were taken by fewer residents after 12 months of the intervention (19.5%) compared with control (50%). No differences in falls rates were observed	71
1	Medication review	2003	Hughes	Information is care: the need for data to assess the quality of care in UK nursing and residential homes	Expert opinion on drug safety	Expert opinion	There is a lack of data on prescribing	72
1	Neuroleptic de-prescribing	2002	Ballard	Can psychiatric liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities	International Journal of Geriatric Psychiatry	Non-randomised controlled trial	Liaison service was associated with a reduction in use of neuroleptics and a decrease in deterioration of expressive language skills, but no change in well-being. There were fewer GP contacts	73
1	Medication review	2000	Khunti	Effect of systematic review of medication by general practitioner on drug consumption among nursing-home residents	Age & Ageing	Evaluation	A total of 51% of patients had a medication stopped and 26% of patients changed to a cheaper alternative or reduced dosage	74
1	WHELD	2016	Ballard	Impact of WHELD intervention on neuropsychiatric symptoms, antipsychotic use and quality of life in people with dementia living in nursing homes: a cluster randomized trial	American Journal of Psychiatry	Factorial cluster randomised controlled trial	There was a reduction of antipsychotic prescription by 50% with a reduced mortality. Social interaction and exercise mitigated the detrimental impact of de-prescribing antipsychotics on neuropsychiatric symptoms	75
1	WHELD	2018	Ballard	Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster-randomised controlled trial	PLOS Medicine	Cluster randomised controlled trial	Improvement in quality of life, agitation and neuropsychiatric symptoms. Rates of prescribing of antipsychotic were low and did not change	76
1	WHELD	2020	Ballard	Improving mental health and reducing antipsychotic use in people with dementia in care homes: the WHELD research programme including two RCTs	Programme Grants for Applied Research	Programme report	A systematic review found four training manuals with randomised controlled trial evidence. Meta-synthesis identified four key elements, including antipsychotic review by GPs. A factorial randomised controlled trial showed a reduction in drug use, and exercise and social interaction were needed to mitigate detriment of drug withdrawal. Focus groups indicated need for a whole-home approach, including sustained relationships. A 9-month randomised controlled trial showed improvement in quality of life, agitation and neuropsychiatric symptoms. Health and social care costs were reduced. Delivering the intervention required a flexible approach. An e-learning module was developed for GPs	77
1	Shine	ND	Baqir	Blogs	Health Foundation	QI	Various aspects of a QI initiative are described, including responding to diversity of GP working practices	78–80
1	Shine	2014	Northumbria Healthcare NHS Foundation Trust	Shine 2012 final report. A clinico-ethical framework for multidisciplinary review of medication in nursing homes	Health Foundation	QI	Similar to Baqir 2013	81
1	Shine	2014	Baqir	A clinico-ethical framework for multidisciplinary review of medication in nursing homes	BMJ Open Quality	QI	Similar to Baqir 2013 (see below)	82
1	Shine	2013	Baqir	A clinico-ethical framework for multidisciplinary review of medication in nursing homes: a Health Foundation Shine project	International Journal of Pharmacy Practice	QI	A total of 422 residents were reviewed and 17.4% of medicines were stopped (6% were stopped because of safety concerns). A total of 2.1% of residents had potential adverse events, but these were reversed. One-hour nursing time was released per day because of fewer medications. Care home nurses and GPs were supportive and allowed access to records	83
1	Shine	2017	Baqir	Impact of medication review, within a shared decision-making framework, on de-prescribing in people living in care homes	European Journal of Hospital Pharmacy	QI	A total of 70.6% of patients had at least one medicine stopped. No significant difference in medicines stopped between pharmacists alone or pharmacist plus GP	84
1	Medication review	2006	Zermansky	Clinical medication review by a pharmacist of elderly people living in care homes – randomised controlled trial	Age & Ageing	Randomised controlled trial	Pharmacist recommended to GP 3.1 drug changes whereas GP alone made 2.4 changes per patient. There was a lower rate of falls in pharmacist-attended residents (0.8 vs. 1.3 falls per patient for the GP group). A total of 75.6% of pharmacist recommendations were accepted and, of these, 76.6% were implemented	85
1	Independent prescribers	2016	Bond	GP views on the potential role for pharmacist independent prescribers within care homes: Care Homes Independent Pharmacist Prescribing Study (CHIPPS): ‘there has to be something in it for me’	International Journal of Pharmacy Practice	Qualitative interview study	GPs welcomed the pharmacist service. Some concerns about pharmacist initiating medicines. Issues raised: trust, governance and knowledge of older people’s medicine	86
1	Independent prescribers	2019	Inch	The Care Home Independent Prescribing Pharmacist Study (CHIPPS) – a non-randomised feasibility study of independent pharmacist prescribing in care homes	Pilot and Feasibility Studies	Non-randomised feasibility study	A total of 44 general practices and 16 pharmacists were recruited and were retained. Forty residents were recruited and were retained. Outcomes selected were number of falls, Drug Burden Index score, hospitalisations, mortality, activities of daily living and quality of life. The service was well received by care homes and GPs	87
2	Difficult Conversations	2018	Brighton	‘Difficult Conversations’: evaluation of multiprofessional training	BMJ Supportive & Palliative Care	Evaluation	A total of 655 participants, including GPs, nurses, social care staff, allied health professionals and care home staff. All groups showed increased self-confidence, knowledge and skills. They appreciated interprofessional learning	60
2	GSF-CH	2009	Badger	An evaluation of the implementation of a programme to improve end-of-life care in nursing homes	Palliative Medicine	Evaluation	Significant improvements in end-of-life care, increase in proportion of residents who had an ACP and increase in proportion of residents who died in the care home. Crisis admissions to hospital were reduced	88
2	GSF-CH	2011	Hall	Implementing a quality improvement programme in palliative care in care homes: a qualitative study	BMC Geriatrics	Qualitative study of QI	Benefits included improved symptom control, team communication, external support (including GP), staff confidence, residents’ choice, reputation of home Barriers included increased paperwork, lack of knowledge, costs, problems with lack of co-operation of GPs	89
2	GSF-CH	2012	Badger	An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation	International Journal of Nursing Studies	Qualitative and quantitative evaluation	Challenges to collaboration: working with many GPs and poor access to out-of-hours and specialist services. Improved collaboration was identified by 33% of managers. Staff reported increased knowledge and confidence, and discussing care with GP and palliative specialists	61
2	GSF-CH	2014	Kinley	The provision of care for residents dying in U.K. nursing care homes	Age & Ageing	Review of deceased care records	Dependency of residents increased, with 56% dying within 1 year of admission. Within the last 6 months of life, support from health-care specialists was variable	90
1	CMHT	2018	Stewart	Provision and perceived quality of mental health services for older care home residents in England: a national survey	International Journal of Geriatric Psychiatry	Survey	Only 18% of CMHTs for older people allocated staff for care homes and services varied. Forty per cent of teams provided training to care homes staff. Service manager was likely to report their service as good if the service had a systematic process for reviewing mental health and antipsychotic prescriptions, including contact with a GP	91
NA	Nutrition review	2014	Madigan	A cluster randomised controlled trial of a nutrition education intervention in the community	Journal of Human Nutrition & Dietetics	Cluster randomised controlled trial	GPs and nurses who attended an educational intervention about supporting patients following discharge from hospital showed greater knowledge than the control, although this was not sustained at 6 months	92
NA	Stroke	2017	Sadler	Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement	PLOS ONE	Qualitative study	Thirty-seven participants, including GPs, selected the following purposes as priorities for data improvement: continuity of care, mental health, access to health and social care, and multiple risk factors. From this consultation, a decision support tool was co-designed	93
NA	Quality and Outcomes Framework	2011	Shah	Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study	British Medical Journal	Quantitative retrospective	Quality indicators of chronic disease care were lower for residents of care homes than for the community over 14 out of 16 indicators (after adjustment). Residents of care homes were more likely to be excluded by GPs from targets within the Quality and Outcomes Framework	94
NA	Fracture prevention	2008	Cox	Educating nursing home staff on fracture prevention: a cluster randomised trial	Age & Ageing	Cluster randomised trial	There were no differences between the intervention and control in primary outcomes, incidence of total fractures or total hip fractures. No differences were found for falls or hip protector use. An increase in prescription of bisphosphonate, calcium and vitamin D was observed in the intervention group	95

These articles and grey literature are arranged according to the programme theory for which they provide evidence. Four articles did not provide in-depth description of the role of the GP and were not consistent with either programme theories 1 or 2 and are, therefore, noted as not assigned.

Steps 3 and 4: extracting and organising data, synthesising evidence and drawing conclusions

Owing to the iterative and cyclical nature of steps 3 and 4, as outlined in Figure 1, we have presented these steps together. Across the 30 articles found and included in the review, there was often only superficial or passing mention of GP involvement in improvement. From these 30 articles, we were able to piece together two main programme theories: one relating to negotiated working with GPs around local improvement initiatives and one outlining the role of GPs in a national improvement programme. Table 3 lists the main articles used to develop the programme theories. In addition, Table 3 lists articles that did not contribute to theory development and provides the reason for exclusion.

TABLE 3 - Evidence used to establish programme theory

CHIPPS, Care Home Independent Prescribing Pharmacist Study; CMR, clinical medication review; EVIDEM-EoL, Evidence-based Interventions in Dementia–End-of-Life; GFS-CH, Gold Standard Framework for Care Homes; RCT, randomised controlled trial; WHELD, Wellbeing and Health for People with Dementia.

Programme theory	CMO	Main study used	Articles limited in relevance or rigour	Rationale for exclusion
Programme theory 1: negotiated working with GPs on local improvement initiatives	CMO 1: pharmacist-led medication review	CMR,83 CHIPPS85,87	Data for quality72	Rigour: commentary without empirical evidence
			RCT: pharmaceutical care71	Relevance: limited involvement of GP
		Shine84	Pharmacist independent prescribers86	Richness: limited description of change
			Evaluation of Vanguard69	Relevance: described future improvements
	CMO 2: de-prescribing, working with care home staff	WHELD77	Evaluation of national policy70	Relevance: no description of change
			Medication review by GP74	Richness: limited description of change
	CMO 3: collaborating for end-of-life care	EVIDEM-EoL67	Quality indicators for end-of-life care66	Relevance: could not engage GPs in improvement
			Implementing new care model 65	Relevance: unable to attribute change to care home
Programme theory 2: role of GPs in supporting national improvement programmes	CMO 4: GP-led end-of-life care	GSF-CH61,89,96	Critique of GSF-CH study97	Rigour: opinion piece
			Response to critique98	Rigour: opinion piece
		Difficult Conversations60

Programme theory 1: negotiated working with general practitioners around local improvement initiatives

We found only a small number of articles about local or regional improvement initiatives that were primarily led by GPs. We found no articles describing how GPs became involved in initiatives, what role they played, what resources were involved or how projects could be sustained or replicated. We did, however, find evidence of initiatives that were led by other professionals where GPs formed part of the mechanism by which outcomes were realised. These are summarised in Figure 3.

FIGURE 3.

Programme theory 1: negotiated involvement of GPs in local improvement initiatives.

In each of the examples found, an initiative that commenced outside general practice was deliverable only through the direct involvement of GPs. To each initiative, GPs brought technical medical expertise, their understanding and an overview of how health-care delivery in the community operates. In addition, GPs also provided a legitimising function by virtue of their role as the doctor, with overall responsibility for co-ordinating patient care in the community. Their role within the improvement initiative had to be negotiated and worked out. The professionals, or external practitioners, had neither the expertise nor authority to specify the role that GPs should play within the improvement programme and this had to be worked out in conjunction with GPs, alongside their competing responsibilities outside the care home setting.

We present here three exemplar CMOs where similar principles played out. These relate to:

1. pharmacist-led medication review (CMO 1)

2. psychotropic de-prescribing led by psychiatrists and clinical psychologists (CMO 2)

3. teamwork focused on reducing uncertainty in end-of-life care (CMO 3).

Exemplar CMO 1: pharmacist-led medication reviews

The schematic outlining this CMO is provided in Figure 4 and details of supporting evidence for each component is provided in Table 4.

FIGURE 4.

Schematic of exemplar CMO 1: pharmacist-led medication review.

TABLE 4 - Summary of evidence for exemplar CMO 1

Context	Mechanism	Outcome
Medication review is challenging and complex (interview #16)84	Trusted relationship between GP and pharmacist develops within framework of consultations (interview #19)84,85,87	Reduction in inappropriate polypharmacy, reduced costs, reduced falls and reduced hospitalisation84,85
Multidisciplinary meetings with a focus, including prescribing9,84	Negotiated adaptation of implementation to take account of diverse ways of working, enabling GP to engage in a way that is consistent with their working practice81,84	Where GP attended a MDT there were greater numbers of prescription changes per resident84 Resident input into meetings78
GP fear of adverse events and responsibility for these81	GP authorises the process, but does not contribute to individual resident reviews81,85	Fewer medication changes may be implemented

Table 4 identifies key references or quotations from interview transcripts and greater detail of analysis is given in Appendix 5. Qualitative analysis software (NVivo 12) was used to create codes that detailed aspects of context across all sources of evidence for pharmacist-led medication review. This coding is summarised in Table 4, column 1. In a similar way, mechanisms were coded and summarised in Table 4 to match the context described in those sources. Finally, where outcomes were measured or observed, these were also extracted (see Appendix 5), summarised and aligned with the contexts and mechanisms (see Table 4). Some sources indicated a lack of outcome (see Table 4, bottom row) and for these problems or deficiencies in the context were identified that explain the lack of firing of mechanisms (see Appendix 5). Our interpretation of a synthesis of CMO across multiple evidence sources is represented in the schematic (see Figure 4).

The medication review projects, which have been described in several programmes82,87 in England, introduce an intervention that modifies the context. The intervention involves new personnel to supplement the GP input (e.g. a pharmacist-independent prescriber) and the additional process of collecting information about the individual. 85 The latter includes extracting information from the GP records, as well as care home records (e.g. to identify any falls). This provisional step requires GP approval. 86

The mechanism of the polypharmacy medication review initiative is the trusting relationship between the pharmacist and GP. In a feasibility study, the Care Home Independent Prescribing Pharmacist Study (CHIPPS),87 all GPs recruited to the study (44 practices in total) remained throughout the study, and success of recruitment and retention was attributed to selecting those with existing relationships with prescribing pharmacists. A quotation from our theory-gleaning interviews with GPs illustrates the importance of communication within relationships:

. . . someone comes out of hospital, there has been a medication change that hasn’t gone on a discharge summary. So, to me having the care home pharmacist liaising with the home, liaises with the manager . . . does a review when someone has been discharged from hospital to reconcile the meds [medications].

GP#21

Another medication review initiative was a QI project called ‘Shine’. GPs were involved in several cycles of QI, during which the model of interaction with GPs varied. 81 The project team recognised that the diversity of GPs’ working routines meant that there needed to be flexibility in how the pharmacist interacted with them. The preferred way of working was when the GP attended the multidisciplinary meeting with the pharmacist and the care home staff, and this occurred for 38% of resident participants. When the GP was not able to attend the multidisciplinary meeting, the pharmacist was able to meet with the GP after the meeting to discuss cases, and this happened for 30% of residents. For the remaining 27% of residents, the pharmacist carried out the medication review with only occasional discussions with the GP about changes in medication. 78,81 Within these models, patients could also be referred to an old age psychiatry service, enabling access to further expertise around the particularly challenging prescribing and de-prescribing decisions for psychotropic medications. A key role was identified for GPs in facilitating shared decision-making with the resident, involving family or advocate when possible, and further discussing decisions with care home managers and staff. 78,81

A key context is the complexity of prescribing for care home residents, particularly the cumulative impact for those living with multimorbidity. The policy context for this comes from national (England) clinical guidance99 and the policy framework for primary care networks,100 which specify the need for regular medication review in care homes. Although there is broad agreement on the importance of medication review, the resources required to complete medication review for care home residents mean that they are time-consuming, require a level of health literacy not always present with residents and their representatives, and exceed the available resource in general practices:

. . . there is little support for practitioners who wish to stop medicines. Solutions to support de-prescribing include tools which identify potentially inappropriate medication, such as the STOPP-START tool and Beers criteria.

Baqir et al. 84

The outcome in CMO 1 is that the individual resident benefits from multidisciplinary expertise and is consulted on proposed changes to medications. Outcomes from the ‘Shine’ project indicate benefits in terms of direct cost saving, reduced falls and reduced hospitalisation. 84,85 The cost saving was greatest for the model in which the GP played a permissive role, rather than contributing directly to the MDT (because GP time did not have to be included in costs). However, the model in which the GP attended the MDT meeting led to a larger number of changes of medication, which may indicate a more thorough, or person-centred, review. 84 Overall, the GP supports and approves the medication review and integrates the intervention into broader care planning, for example taking account of prognosis and likely clinical trajectory. This was supported by one of our theory-gleaning interviews with a GP who outlined that medical input, provided by GPs, was required to contextualise prescribing decisions in wider plans for medical management:

We then set aside an hour where we will go through the ones where she is considering stopping, or this person has got this illness and they haven’t got this drug. And so, she doesn’t make any of the decisions on her own, those decisions are made with me with my clinical knowledge of the patient.

GP#21

The GP may also be best placed to interact with residents and family members to facilitate shared decision-making, a key role identified within the ‘Shine’ QI project:82

. . . decisions are based on having conversations around context and I don’t know many pharmacists who are sighted on being like the Mental Capacity Act and how we should be making decisions based on a person’s wishes and preferences or who is the legal decision maker authority is and then having a conversation.

GP#19

The interviews highlighted that GPs remain the accountable professional for patient care during and after medication reviews, and that any problems arising from review would return to the GP. Building trust with the pharmacist and the broader MDT was necessary for GPs to permit medication reviews to proceed. The limitations placed on implementation if GPs were not reassured about its safety were noted in one study by Zermansky et al. 85 as follows:

The low implementation rate might have been higher if the pharmacist had been allowed to implement agreed changes. 85

In summary, when a QI project reviews medication of care home residents using a structured process that seeks input from resident and care home staff (context), then a trusting relationship between pharmacist and GP can facilitate the procedure, enabling combination of the structured approach and specialist knowledge of the pharmacist with the medical expertise of the GP (mechanism). This results in successful reduction of inappropriate polypharmacy with measurable improvement in care and cost savings (outcomes).

Exemplar CMO 2: psychotropic de-prescribing led by psychiatrists and clinical psychologists

This second CMO focused on how a QI prescribing innovation linked to a specific goal of reducing antipsychotic prescribing relied on working with GPs. It refines the earlier evidence and draws on a rigorous programme of research that specifically engaged with the care home staff and how they worked. The schematic outlining of this CMO is shown in Figure 5 and a detailed explanation of the components of the CMO with supporting evidence is provided in Table 5.

FIGURE 5.

Schematic of exemplar CMO 2: de-prescribing antipsychotics.

TABLE 5 - Summary of evidence for exemplar CMO 277,101

Context	Mechanism	Outcome
GP co-designed training for GPs	GP gains confidence in ability of care home manager	Proactive working to de-prescribe
Care home delivers social intervention and nudges GP to de-prescribe	GP feels reassured that alternative therapy to antipsychotic is being provided	De-prescribing of antipsychotics, leading to cost savings and reduced side effects of antipsychotics

People with dementia can exhibit behavioural or psychological symptoms of dementia that staff find challenging and difficult to manage. The causes of these behaviours are often a communication of a particular issue, for example undiagnosed pain or environmental factors. Prescribing antipsychotics for these symptoms is increasingly recognised as associated with adverse outcomes. National policies have encouraged a reduction in the frequency antipsychotic prescriptions. 102

Ballard et al. 77,101 led a programme of research to develop multifactorial approaches to behavioural and psychological symptoms of dementia that could reduce the need for antipsychotic medication. This programme of research was called Wellbeing and Health for People with Dementia (WHELD). 77,103 The research team included psychiatrists and clinical psychologists who developed a psychosocial intervention. The intervention had four components: (1) person-centred care training for staff, (2) review of antipsychotic medication by the resident’s GP, (3) a social interaction component and (4) an exercise component. The programme developed training and resources to support GPs in carrying out de-prescribing:

Physicians were invited to an interactive seminar and/or practice meeting, provided with a toolkit or best practice guide, and given an opportunity for detailed discussion, including scenarios with individual patients.

Ballard et al. 101

Therefore, the context of this CMO was the improvement project that was led by psychiatrists and clinical psychologists. Care home staff were trained to provide social interaction as a non-pharmacological alternative to antipsychotic medication. Alongside this, staff were encouraged to support GPs in reviewing medication. 77,101 Similar to the previous mechanism (i.e. CMO 1), the relationship of the GP with other members of the care team is important, but, here, the care staff are responsible for the initiative. Therefore, the training and activity in the care home to identify alternative non-pharmacological interventions and greater awareness of the harms of antipsychotics among the team provided the context in which the GP de-prescribed. The initiative was supported by additional training that was co-designed with GPs and developed into a digital learning package. The opportunity and increased confidence afforded GPs (i.e. that care home staff were equipped to offer alternative approaches to care) represented a mechanism whereby de-prescribing could occur, delivering key outcomes around reduction of polypharmacy and harm.

Exemplar CMO 3: general practitioner integral within change initiative to improve end-of-life care

The schematic outlining this CMO is provided in Figure 6 and details of supporting evidence for each component is provided in Table 6.

FIGURE 6.

Schematic of exemplar CMO 3: delivery of end-of-life care using appreciative inquiry.

TABLE 6 - Summary of evidence for exemplar CMO 3

Context	Mechanism	Outcome
Different perspectives were held by the GP and the care home manager. The usual routine of GP care may not suit residents with complex needs67	Appreciative inquiry identified shared opportunities. GP taking a collaborator role rather than leader (GP interviews #11 and #21)67	Implementation of tools and processes improves consistency of care67
GPs reflect on visiting frequency and co-ordination with out-of-hours teams and district nurse to support care home68	Collaborative support to enable end-of-life care to be provided in care home and to implement ACPs68	More frequent visits reduce need for emergency care68

A care home improvement project about end-of-life care used an appreciative inquiry method to bring together the care team. The project had identified areas of uncertainty within teams when decisions had to be made about end-of-life care and this could lead to conveyance to hospital towards the end of life. 67 A series of three workshops brought together the care home manager, GP and district nurse, from three care homes. Appreciative inquiry enabled issues to surface, including who should lead care decisions, communication and care routines. This approach engaged GPs in how changes were planned and elicited the commitment to deliver the agreed change. Discussions explored different perspectives that members of the team may bring to care of individual residents. Tools and frameworks were implemented through the project67 and these, together with the above issues, may be considered as context within CMO 3.

Reflecting on our theory-gleaning interviews, we can add greater depth to our understanding of context. GP participants mentioned that communication could be a challenge, with care home staff at times feeling ‘isolated, unsupported and unheard’ (GP#21). Communication difficulties may be linked to different approaches between GPs and care home staff, with one participant indicating that the ward-round approach, which may be the approach favoured by GPs, was not optimal for patients with complex needs (GP#11).

Further evidence for this CMO can be drawn from a project that used audit and feedback to improve GP involvement in end-of-life care and urgent care. 68 Case notes of residents of six care homes, all registered with one general practice, were audited, and data were presented at a multidisciplinary study day with care home managers and staff, GPs, out-of-hours staff and district nurses. A follow-up audit showed changes in GP attendance at care homes and reductions in emergency admissions to hospital. The different contexts of the residential and the nursing home were analysed. Although the number of residents admitted to hospital by GPs attending residential and nursing homes decreased, for residential homes there was an increase in the number of residents admitted to hospital following the care home staff calling for an ambulance, but this did not increase for nursing homes. One aspect of the improvement work was to encourage discussions about preferred place of care and death between residents and family, care home staff and GPs. The outcome was an increase in deaths within both residential and nursing homes and an equivalent decrease in deaths in hospital. GPs reflected that they had spent more time with residents and that this enabled better advance care planning. The audit data showed an increase in visits for nursing home residents. 68 Finally, it should be noted that a GP conducted this study and, although it is not explicitly stated, the GP led the improvement initiative.

Context–mechanism–outcome 3 may be summarised as follows: GPs and care home managers may hold different perspectives and approaches to complex care and end-of-life care, and these can lead to uncertainties (i.e. treatment uncertainty and service uncertainty) (context). When a resident is deteriorating there may be different views about capacity of the home to provide care or, alternatively, if the resident needs to be transferred to hospital, and this will be influenced by availability of GP (or out-of-hours team) and if there is on-site nursing or access to a district nurse for residential homes (context). Appreciative inquiry and audit and feedback methods have been used to develop collaborative relationships between GPs and care home managers. A GP interview participant described the relationship as a ‘whole team’ (GP#21). This mechanism identified shared opportunities and approaches to end-of-life care (mechanism). The outcome was implementation of care planning tools that addressed uncertainty and delivered co-ordinated care, leading to fewer residents being admitted to hospital and more residents dying in the care home (outcome). 67,68

Programme theory 2: role of general practitioners in supporting national improvement programmes

We found limited evidence of national initiatives for which GPs were involved in improvement programmes in care homes around the country in a consistent way. Although under way as we conducted the research, the EHCH programme of NHS England had hitherto conducted its work as part of local pilot initiatives known as ‘Vanguards’. 9

There were two examples of nationally co-ordinated care home improvement initiatives focused on end-of-life care that had evidence of GP involvement: (1) a series of studies describing the development and evaluation of the Gold Standards Framework for Care Homes (GSF-CH), which is a structured way to prognosticate and deliver appropriate care to people as they approach the end of their lives,61 and (2) a study that described the development and implementation of a programme called ‘Difficult Conversations’. 60 The schematic for this programme theory is illustrated in Figure 7 and supporting evidence is outlined in Table 7.

FIGURE 7.

Schematic of programme theory 2.

TABLE 7 - Summary of evidence for the CMO of programme theory 2

Context	Mechanism	Outcome
Programme aligns with existing initiatives in place in general practice61	GPs can integrate improvement with existing models of working61	Improved confidence in individual and team decisions, and clearer understanding of roles and responsibilities between GP and care home61,89
Training provides care home staff with a structured way to communicate with GP61	GPs and care home staff have a shared framework for understanding end-of-life care decisions89	Improved use of shared documentation and communication of care around dying residents61
Specific GP-focused learning outcomes and training delivered as part of a multidisciplinary training programme60	GPs can understand and feel confident in their role in the team60	Improved multidisciplinary working around end-of-life care60

There is some overlap between this CMO and the exemplar CMOs used in support of programme theory 1. We separated this CMO because of an observation that impetus for national roll-out of each of these programmes came from an influential leader who was also a GP. We looked for evidence that their status as a GP was, in some way, integral to the success of these programmes at a national level, but we were unable to find this. Nevertheless, we have separated this CMO into a programme theory to illustrate that the impetus for change came from within, rather than outside, general practice, which is a key distinction from the exemplars given in support of programme theory 1.

The Gold Standards Framework (GSF) was developed to support GPs delivering end-of-life care to people in their own homes and, more recently, this has been adapted into the GSF-CH. The main part of the implementation of the GSF-CH is about training care home staff and accrediting care homes. There seems to be an assumption that the GP for the care home is also GSF accredited and, therefore, enabling the care home and GP to collaborate using the same framework for end-of-life care. The many reports and evaluations61,88,89 of GSF-CH describe the care homes’ role and their communication with their GP, but do not explicitly state the role of the GP in implementing GSF-CH or how this has changed (improved) the GP’s care of the individual.

As the GSF programme was well established in general practice and the framework deployed in care homes was largely similar to that used in the community (context), this made it easier for GPs to integrate it into existing models of working (mechanism). In addition, the shared framework between GPs and care home staff led to a shared understanding of end-of-life care decisions (mechanism). There was evidence that care homes accredited with GSF-CH experienced more respectful communication with GPs. 61 The outcomes were better understanding of the roles and contributions of care home staff and GPs, improved use of shared documentation and improved communication of care around dying residents, with the results that the team (i.e. the GP and care home) made decisions more confidently and had greater confidence in their decisions (outcome). The framework (i.e. the process, accreditation and the documentation) could be considered to act as a boundary spanner between the GP profession and the care home sector:

The focus is on organising and improving the quality of care for care home residents in the last year of life in collaboration with GPs, primary care and specialist palliative care teams.

Hall et al. 89

The ‘Difficult Conversations’ programme was evaluated by Brighton et al. 60 This was an evaluation of delivery of multiprofessional training, including GPs and care home staff. The supplementary appendix of the article60 states that a GP was involved in developing the intervention. Furthermore, GPs were trained to be champions to deliver the training (i.e. a train-the-trainer model). 60 Participants who received training completed a self-report questionnaire on their confidence, knowledge and skills in communicating about end-of-life care with patients and carers. Neither the training nor the evaluation were specific to the care home setting, but participants included care home staff (6% of participants), as well as community nurses and allied health professionals. GP participants showed a small but significant increase in self-reported confidence and skills about end-of-life care. Other staff groups showed a greater increase, although this appeared to be partly due to the GPs starting at a higher baseline score. In response to open questions, participants said that they valued the interprofessional learning:

They praised the expertise of the workshop facilitators (n = 64), noted the benefits of interprofessional learning (n = 36). 60

This evaluation indicates that the course may have given increased confidence, not only of the GPs ability, but also confidence in the ability of the multidisciplinary care team.

The founder of the GSF programme is a national leader for general practice, Dame Professor Keri Thomas:

The GSF was developed by generalist practitioners to address their own needs for support and education related to end-of-life care. 61

The ‘Difficult Conversations’ programme was led by Dr Catherine Millington-Sanders, who is a clinical champion for end-of-life care for the Royal College of General Practitioners and the Marie Curie Foundation (London, UK). The website for the programme states that it is endorsed by the Royal College of General Practitioners, General Medical Council (London, UK) and British Medical Association. Whether senior GP leadership for these initiatives, or the sponsorship of national umbrella organisations, confers credibility in the eyes of GPs or increases the likelihood that they will engage with the programme is not clear. It is, however, a potentially important structural difference from the initiatives described by programme theory 1. GPs did play a more direct role in the implementation of ‘Difficult Conversations’ than in all of the other programmes described, at least by design. However, the precise detail of the work undertaken by individual GPs as part of either of these national initiatives was not well reported in the literature.

Programmes in which the evidence was too thin to describe mechanisms

We identified programmes that did not fit the above programme theories; however, the evidence was too thin to describe realist mechanisms. One article74 describing medication review was authored by GPs and, by implication, the project had been led by the GP authors; however, there was no description of how the GP carried out the review and, therefore, it was not possible to describe mechanism or CMO configuration. Another programme53 described a general practice that had been set up to provide specifically for care homes, but, again, there was insufficient evidence to describe a CMO.

General practitioner carrying out medication review

One early study,74 which claims to be the first report of medication review in care homes, was conducted by two GPs, rather than pharmacists. The authors conducted the medication reviews with nursing homes where patients were registered with their own practice. The number of prescriptions was reduced (from mean of 4.3 repeat prescriptions to a mean of 3.5 repeat prescriptions) in residents reviewed. 74 There was a lack of depth of description about the process of the medication review. It may be that the GPs had capacity within a specific role (e.g. research) to carry out reviews. The care homes were local to the general practice and, therefore, they may have well-established relationships with the care home managers, which would be part of the context. This GP-led medication review project74 is consistent with some aspects of CMOs 1 and 2, but there is no evidence of resources required for the initiative, how it was established and if it could be sustained or replicated. 74

General practitioner specialising in care homes

Our understanding of recent policy in England led to drafting a putative programme theory about general practices that cared for care home residents only. We considered that if this were the case, or if policy was developing in this direction, it would support the development of GPs with special interests (or extended role) in older people’s care and care homes. Therefore, we conducted further scoping searches for these topics. We received an informal report about one care home-specific general practice and found a brief mention of another example (Dr Louise Butler, Salford Royal NHS Foundation Trust, 2020, personal communication). However, we were unable to identify any further literature and, therefore, the evidence was insufficient to be able to elaborate this putative programme theory.

Chapter 4 Discussion

The starting point for this realist review was findings from our own research studies9,37,104 and experience from our own improvement practice30 that suggested that GPs are integral to service delivery in care homes. As the source of medical support and access to specialist care for care home residents, GPs hold a position of significant power and influence over residents’ care and health-care improvement in these settings. We had expected to find within the QI literature accounts of how GPs had been involved, descriptions of how they negotiated their role in relation to other visiting health-care professionals and information on what supported the development of relationships over time. We were particularly interested to identify patterns of GP involvement that led to improved staff outcomes and systems of working at the interface between health and social care. The review, however, demonstrated that this is an unexamined role in contrast to work on the specialist contribution to care homes. 47 The paradox is that the GPs are central to recent policy for enhancing health-care provision to care homes, despite questions about GP capacity to fulfil this, and the relative effectiveness of core activities and practices that GPs fulfil when working with care homes, such as medication management, end-of-life care and working with others, remain neither tested nor compared with the input of other visiting health-care professionals. The interviews and scoping confirmed the central role of the GP as the provider of medical care to residents, but without agreement about the responsibilities and role. How the GP role enabled QI to occur (or not) relied on how working relationships were negotiated. Specifically, it depended on the presence of the following factors: the GP role as facilitator and endorser of change, GP involvement in co-designing innovations, ability of GPs to prioritise this work against the larger caseload and, finally, GPs having the resources and expertise to support the work.

There is a growing literature on care home innovation and sophistication in understanding how contextual factors affect uptake and engagement. 105,106 GPs’ input is acknowledged as part of this, but, to the best of our knowledge, how they co-ordinate or integrate with care homes has not been explained or discussed in detail. 48 The fact that GPs have not featured significantly in descriptions of care home improvement work to date could mean that their role has been taken for granted as core, but not described. Alternatively, it could be that the need for QI is a reflection of the absence of GP involvement in particular aspects of care delivery in care homes. If the level of GP engagement in care home work has historically been discretionary or dependent on the quality of working relationships, are studies of QI recognising gaps in provision that could or should be GP-led work? Are they compensating for limited medical engagement or limited access to specialist care that can deliver improved outcomes? The literature about the role of GPs in improvement in care homes raised questions about the capacity of GPs to deliver and what system-based expectations existed as to what is, and is not, the role of the GP. 61,65–95,101 This resulted in the following:

• GPs were not the instigators or leaders of improvement initiatives in the setting.

• The role of GPs was always negotiated to take account of their likely contribution as primary care doctors and the ways in which they could use their unique skills and competencies as part of a MDT to deliver improvement goals.

• What was generalist (GP) work, and appropriate to expect GPs to fulfil, was unclear. Often QI required additional training to orientate GPs to technical components of an intervention, for example around behavioural and psychological symptoms of dementia and antipsychotics. In the contexts described these activities went beyond core GP work. They were represented as new skills. It was not clear from the articles included in our review, our interviews, or subsequent consultations whether or not being able to respond to needs commonly experienced by care home residents was core or specialist GP work.

• Training about frameworks (e.g. around structured approaches to polypharmacy or end-of-life care) that could inform interactions between GPs and care home staff, or other professionals, such as pharmacists, was negotiated, was not core and could not be assumed as in place for improvement work.

• Building trust through communication and shared understanding of roles and responsibilities was a recurrent mechanism by which GP support could be enlisted for improvement initiatives. This was particularly the case when reassuring GPs about mitigating risk of adverse events for which they were nervous about assuming subsequent responsibility.

For each of the initiatives described (around polypharmacy, antipsychotic de-prescribing and end-of-life care) the improved outcomes identified could be achieved through GP involvement only. In polypharmacy, this related to the unique ability of GPs to balance prognosis and diagnosis alongside consideration of drug–drug and drug–patient interactions. For antipsychotic de-prescribing, it related to the GPs’ role as the first-line provider of health care and the usual prescriber in care home settings. Finally, for end-of-life care, it related to the role of GPs as a specialist medical contributors to a MDT, which enabled that team to make decisions with confidence, avoiding uncertainty and indecision that could lead to adverse outcomes for care home residents. In each of these instances, although GPs did not lead change, they were instrumental to its delivery. They could not have been ‘written out’ of any of the programmes described.

A recurring context necessary to lead on to GP engagement was identifying and agreeing the unique contribution of GPs within the QI initiative, either from the outset or as an integral part of the work. This worked best when the QI initiative focused on what it was that GPs, and GPs alone, could provide, and structured the approach accordingly to facilitate the input of GPs. GPs then had an active role in iterative development of medication reviews, in co-designing training aimed at GPs around behavioural and psychological symptoms of dementia and antipsychotic de-prescribing, and in designing care home-specific approaches to end-of-life care. In each instance, however, GPs helped determine how the intervention would interdigitate with general practice, rather than taking a more overarching leadership role. Innovation was required to design ways of making improvement initiatives fit in, or adapt to, existing systems so that what was asked of GPs was recognised as part of their core role and complemented the wider caseload. Examples included two national initiatives – the GSF-CH and the ‘Difficult Conversations’ programme – in which GPs played a central role. These examples provide evidence that GPs can, and have, led QI initiatives in the care home sector; however, there remains an absence of description of the different ways that GPs were able to initiate and sustain change. It also was not clear, despite such initiatives being framed in a way that complemented and accounted for GP ways of working, the role that GPs actually played in delivering improvements on the ground. These findings add to a growing literature on QI in care homes. Innovation and improvement are not new to care homes. Indeed, there is a rich tradition in the nursing literature of participatory approaches to research and improvement within care homes. These approaches include action research- and appreciative inquiry-based approaches to innovation and improvement. 107 Structured approaches to QI, of the sort that are now widely established among health-care providers, are, however, new to care homes. 37 Managers and staff have shown that they can adopt and adapt such approaches, and that they can use them to improve outcomes for residents,29 but without links to the surrounding systems of care, sustaining improvement is difficult. Care homes are not universally equipped to engage with improvement and a number of organisational factors can influence their ability to support and adapt to change. 105 How to enable care homes to prepare effectively for change is relatively unexplored. The data maturation of the UK care home sector, although substantially accelerated during the COVID-19 pandemic, is still considerably behind that of other long-term care sectors internationally. 108,109 Although regional pilots of benchmarking data for improvement have shown some promise,110 and, although ongoing National Institute for Health Research projects promise to develop a minimum data set for UK care homes,111 further development and implementation will be required to enable data to be readily available for measuring improvement initiatives. 111 There is clearly a role for GPs in this growing programme of work and this review has demonstrated the need to articulate what needs to be in place to achieve meaningful engagement.

All of the programmes discussed in this paper were contingent on GP involvement for some, or all, of their reported outcomes. The EHCH framework roll-out,16 discussed in Chapter 1, Quality improvement and other types of advancing practice, calls for closer working of GPs with care homes. The appointment of clinical leads in the midst of the COVID-19 pandemic is a further indicator of the NHS’s intent to take more direct responsibility for structured health-care delivery to care home residents. However, it could potentially be a mistake to expect GPs to assume a leadership role in QI in care homes when, in fact, other professional groups are arguably better placed to lead such work if they engage directly with GPs to consult and co-design where they will add value.

The strengths of the study were that we took a systematic approach to searching academic and grey literature databases. We followed the RAMESES guidelines for realist review (see Appendix 6). We were able to bring a disparate and diverse literature together to inform our theory development. We used stakeholder interviews and a Context Expert Group, which included GPs, a care home manager, a nurse and a pharmacist, to sense-check emerging programme theories and ensure that they reflected real-world experience. Our expert consultation group also helped our approach to the grey literature to ensure that we did not miss key publications that were relevant to the scope of our review.

Our findings are limited by the paucity of description or discussion in the literature on the role of GPs in QI in UK care homes to date. Although our programme theories are evidenced, and evidence-based, they are based upon a relatively small body of work. To answer the questions of ‘what works, when and in what circumstances’, our findings point to the importance of articulating from the outset what the expected role of the GP is and what resources are required. How relationships between other disciplines and care home staff are negotiated is important and the review found that these are ‘soft skills’ that are built up over time or incorporated into the QI initiative. Focusing on how the QI initiative takes account of the GP as ultimately responsible for the residents’ health care may explain why GPs are cautious to lead and collaborate. If GPs were peripheral or not involved, then this also raised questions about the additional workload generated and the sustainability of the programme.

Much of the international literature failed the relevance test by virtue of the relatively unique role played by GPs within the UK health-care system. This meant that findings from long-term care sectors, in the Netherlands and USA for example, with more evolved approaches to QI in long-term care, were difficult to incorporate. We were also limited to publications in English, which may have excluded significant chunks of literature from the Netherlands in particular. It is possible that our decision to look for case studies in prescribing, end-of-life care and extended role general practice could have excluded important segments of the literature that could have further developed our theoretical understanding. There are initiatives that have changed the organisation of care delivery (e.g. care home-based ‘ward rounds’, asking staff to triage residents by need for GP care, online consultations and use of early warning scores), but we found limited accounts or evidence on how the GP role was negotiated and the impact on the service. We did, however, consult regularly with members of our Context Expert Group expert who were unable to direct us to other sources.

Even taking account of the grey literature, it is possible that the type of QI initiatives that are reported in articles, or on the internet, are externally commissioned and funded formal QI initiatives, and are of the type that are likely to be externally led and highly structured. QI should be a bottom-up approach and integrated into daily working, and we may not have captured smaller, less formal QI initiatives led by GPs. This could have biased our findings. This review made some effort to overcome this by the use of stakeholder interviews and an expert consensus group, which took discussions beyond what was published in the literature. Nevertheless, smaller, bottom-up QI initiatives may have been out of sight to such contributors.

One methodological limitation related to the use of a single reviewer to screen abstracts. This could have been a problem if it led to articles that could have provided important evidence being excluded. This was a consequence of limitations on the availability of team members, several of whom are clinicians, as a result of the COVID-19 pandemic, which coincided with this work. We did, however, conduct multiple secondary searches and regularly checked with our Context Expert Group to ensure that we had not missed key references as a consequence of this. In addition, we were driven by the paucity of evidence retrieved to continually return to the literature in search of more and, if anything, we sought to be inclusive and expand the relevant evidence, reducing the risk that we will have missed important papers.

Chapter 5 Conclusions and implications for practice

Based on our findings, we recommend that for GPs to work as part of QI initiatives in care homes it is important to address, from the outset, their role in the initiative, how they complement the work of other disciplines and the opportunities for them to engage in approaches that support a care home focus (and not just individual patients) when working with care home staff. There is a persistent narrative of conflicting commitments, and the nature of their largely medical expertise, that they are not always the best-placed professional group to lead QI initiatives. 6 GPs do, however, frequently lie on the critical path to success for QI initiatives undertaken in the sector and they are responsible for medical care and referral to other specialist services.

We recommend the following steps for stakeholders involved in QI:

• Meet early with GPs to identify how and when they might contribute to QI initiatives, focusing on their role as medical practitioners and the specific contributions that can be made only by GPs and not by other community-based health or social care professionals.

• Recognise that GPs exist on a continuum of expertise and interest in relation to care homes, and care of older people more generally, and ensure that improvement models allow for likely variability in practice.

• Consider what specialist training, either clinical or QI oriented, GPs might need to engage with the improvement initiative. When possible, co-design this with GPs.

• Consider what adaptations to policies, procedures, documentations and schedules might be required to make best use of GPs as part of an improvement initiative. Recognise that the GPs, care home staff and other professionals may need to train, or work side by side, for a period of time to develop the shared trust and understanding required to build the necessary confidence as a team to deliver improvement outcomes.

• Recognise the impact of QI on longer-term GP working and develop outcome measures to capture this. Demonstrating this impact will enable sustained and repeated engagement with GP colleagues.

For GPs, we recommend the following:

• Be receptive to local QI projects that approach you to support their initiative. Try to have early conversations about the unique input you could contribute and the limits of your capacity.

• Reflect on the working relationship between your general practice and local care homes. Can you concisely convey this working pattern to the QI team? (Other GPs or care homes may work in different ways.)

• Are you confident that you have the specialist skills to support the GP role within the improvement initiative? Within your general practice or network, does one of your colleagues have a special interest in older people’s care, or could you commit to developing your own interest or extended role? Convey and negotiate the necessary training to deliver the GP role in initiative to the improvement team. Be prepared to help design this, and, if you do, it will likely better reflect your needs and those of colleagues.

• Consider how the QI initiative may develop in future. If the general practice has limited capacity or resource at the time, can you make a limited commitment at this stage, but aim to explore future contributions as the project develops?

• Consider how the improvement team can show you, and others, that the project had improved quality, or added value, to care. Be prepared to describe this to the project team so that they can design process and outcome measures that can illustrate this for you and others.

Although this realist review has focused primarily on the role of GPs in improvement, it is important that this is not seen in isolation. We have written elsewhere about the need to engage early and often with care home staff during improvement and innovation in care homes,9,30,37 and the need to build structures to minimise traditional hierarchies and organisational boundaries that serve to disempower care home staff during improvement initiatives. The need to carefully delineate and work to accommodate the unique contribution of GPs does not conflict with, but rather complements, this. Improving outcomes through shared understanding of roles and responsibilities was a recurrent pattern identified during the work undertaken in this review and building opportunities to work together as a team to develop such understanding should be seen as core to good QI in this sector.

Acknowledgements

We would like to thank information scientists Deirdre Andre and Sally Dalton, University of Leeds (Leeds, UK), who constructed search strategies and conducted searches of academic databases.

We would like to thank all interview participants and members of the Context Expert Group for their time and valuable input.

References

1. Gordon AL, Devi R, Williams C, Goodman C, Sartain K, Chadborn NH. Protocol for a realist review of General Practitioners’ Role in Advancing Practice in Care Homes (GRAPE study). BMJ Open 2020;10. https://doi.org/10.1136/bmjopen-2019-036221.
2. Gordon AL, Franklin M, Bradshaw L, Logan P, Elliott R, Gladman JR. Health status of UK care home residents: a cohort study. Age Ageing 2014;43:97-103. https://doi.org/10.1093/ageing/aft077.
3. Gordon AL. What is the case for care home medicine? The geriatrician’s perspective. J R Coll Physicians Edinb 2015;45. https://doi.org/10.4997/JRCPE.2015.213.
4. Iliffe S, Davies SL, Gordon AL, Schneider J, Dening T, Bowman C, et al. Provision of NHS generalist and specialist services to care homes in England: review of surveys. Prim Health Care Res Dev 2016;17:122-37. https://doi.org/10.1017/S1463423615000250.
5. Wolters A, Santos F, Lloyd T, Lilburne C, Steventon A. Emergency Admissions to Hospital From Care Homes: How Often and What For?. London: The Health Foundation; 2019.
6. British Medical Association . Government Needs to Address Problems Facing Care Home Services, Warn GP Leaders 2016.
7. Donald IP, Gladman J, Conroy S, Vernon M, Kendrick E, Burns E. Care home medicine in the UK – in from the cold. Age Ageing 2008;37:618-20. https://doi.org/10.1093/ageing/afn207.
8. Goodman C, Davies SL, Gordon AL, Meyer J, Dening T, Gladman JR, et al. Relationships, expertise, incentives, and governance: supporting care home residents’ access to health care. An interview study from England. J Am Med Dir Assoc 2015;16:427-32. https://doi.org/10.1016/j.jamda.2015.01.072.
9. Goodman C, Davies S, Gordon A, Dening T, Gage H, Meyer J, et al. Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings. Health Serv Deliv Res 2017;5. https://doi.org/10.3310/hsdr05290.
10. Gordon AL, Goodman C, Davies SL, Dening T, Gage H, Meyer J, et al. Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes. Age Ageing 2018;47:595-603. https://doi.org/10.1093/ageing/afx195.
11. Goodman C, Dening T, Gordon AL, Davies SL, Meyer J, Martin FC, et al. Effective health care for older people living and dying in care homes: a realist review. BMC Health Serv Res 2016;16. https://doi.org/10.1186/s12913-016-1493-4.
12. Devi R, Meyer J, Banerjee J, Goodman C, Gladman JRF, Dening T, et al. Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH): a realist evaluation protocol. BMJ Open 2018;8. https://doi.org/10.1136/bmjopen-2018-023287.
13. Dimant J. Roles and responsibilities of attending physicians in skilled nursing facilities. J Am Med Dir Assoc 2003;4:231-43. https://doi.org/10.1097/01.JAM.0000075915.15039.B1.
14. White HK, Buhr G, McConnell E, Sullivan RJ, Twersky J, Colon-Emeric C, et al. An advanced course in long term care for geriatric medicine fellows. J Am Med Dir Assoc 2013;14:499-506. https://doi.org/10.1016/j.jamda.2013.02.012.
15. Koopmans RT, Lavrijsen JC, Hoek JF, Went PB, Schols JM. Dutch elderly care physician: a new generation of nursing home physician specialists. J Am Geriatr Soc 2010;58:1807-9. https://doi.org/10.1111/j.1532-5415.2010.03043.x.
16. NHS England . New Care Models: The Framework For Enhanced Health in Care Homes 2016.
17. NHS England . NHS Long Term Plan 2019.
18. Lloyd T, Conti S, Santos F, Steventon A. Effect on secondary care of providing enhanced support to residential and nursing home residents: a subgroup analysis of a retrospective matched cohort study. BMJ Qual Saf 2019;28:534-46. https://doi.org/10.1136/bmjqs-2018-009130.
19. NHS England and Improvement . COVID-19 Response: Identifying a Clinical Lead For All Care Homes 2020.
20. Pulse . Care Home ‘Clinical Leads’ Will Not Be Held ‘Medically Responsible’ For Residents 2020. www.pulsetoday.co.uk/news/uncategorised/care-home-clinical-leads-will-not-be-held-medically-responsible-for-residents/ (accessed 25 August 2021).
21. Robbins I, Gordon A, Dyas J, Logan P, Gladman J. Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study. BMJ Open 2013;3. https://doi.org/10.1136/bmjopen-2013-003178.
22. Institute of Medicine . Crossing the Quality Chasm: A New Health System For the 21st Century 2001.
23. Wilberforce M, Challis D, Davies L, Kelly MP, Roberts C, Loynes N. Person-centredness in the care of older adults: a systematic review of questionnaire-based scales and their measurement properties. BMC Geriatr 2016;16. https://doi.org/10.1186/s12877-016-0229-y.
24. Nolan M, Davies S, Brown J. Transitions in care homes: towards relationship-centred care using the ‘Senses Framework’. Qual Ageing Older Adult 2006;7. https://doi.org/10.1108/14717794200600015.
25. Corazzini KN, Anderson RA, Bowers BJ, Chu CH, Edvardsson D, Fagertun A, et al. Toward common data elements for international research in long-term care homes: advancing person-centered care. J Am Med Dir Assoc 2019;20:598-603. https://doi.org/10.1016/j.jamda.2019.01.123.
26. Care Quality Commission . Guidance for Providers 2020. www.cqc.org.uk/guidance-providers (accessed 11 January 2021).
27. Department of Health and Social Care . Quality Matters Summary Action Plan: Second Edition 2019. www.gov.uk/government/publications/adult-social-care-quality-matters-action-plan-for-year-2/quality-matters-summary-action-plan-second-edition (accessed 19 May 2020).
28. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Lloyd P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 2009.
29. Marshall M, de Silva D, Cruickshank L, Shand J, Wei L, Anderson J. What we know about designing an effective improvement intervention (but too often fail to put into practice). BMJ Qual Saf 2017;26:578-82. https://doi.org/10.1136/bmjqs-2016-006143.
30. Devi R, Martin G, Banerjee J, Butler L, Pattison T, Cruickshank L, et al. Improving the quality of care in care homes using the quality improvement collaborative approach: lessons learnt from six projects conducted in the UK and the Netherlands. Int J Environ Res Public Health 2020;17. https://doi.org/10.3390/ijerph17207601.
31. Pawson R. The Science of Evaluation: A Realist Manifesto/Ray Pawson. London: Sage Publications Ltd; 2013.
32. Dalkin SM, Greenhalgh J, Jones D, Cunningham B, Lhussier M. What’s in a mechanism? Development of a key concept in realist evaluation. Implement Sci 2015;10. https://doi.org/10.1186/s13012-015-0237-x.
33. Lacouture A, Breton E, Guichard A, Ridde V. The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation. Implement Sci 2015;10. https://doi.org/10.1186/s13012-015-0345-7.
34. Gordon AL, Devi R, Williams C, Goodman C, Sartain K, Chadborn NH. Engaging General Practitioners in Service Development and Quality Improvement for Healthcare in Care Homes: A Realist Synthesis of the Published Evidence. York: University of York; 2019.
35. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. BMC Med 2013;11. https://doi.org/10.1186/1741-7015-11-21.
36. Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Med 2016;14. https://doi.org/10.1186/s12916-016-0643-1.
37. Devi R, Chadborn NH, Meyer J, Banerjee J, Goodman C, Dening T, et al. How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation. Age Ageing 2021;50:1371-81. https://doi.org/10.1093/ageing/afab007.
38. Balbes J. The Practice of GPs Charging Retainers to Care Homes. London: Care England; 2014.
39. Social Care Institute for Excellence . GP Services for Older People: A Guide for Care Home Managers 2013. www.scie.org.uk/publications/guides/guide52/entitlements-and-requirements/access.asp (accessed 2 January 2021).
40. Pulse Today . Care Homes ‘to Stop Paying Retainer Payments to GP Practices’ 2015. www.pulsetoday.co.uk/news/clinical-areas/prescribing/care-homes-to-stop-paying-retainer-payments-to-gp-practices/ (accessed 2 January 2021).
41. Riley AJ, Harding G, Meads G, Underwood MR, Carter YH. An evaluation of personal medical services: the times they are a changin’. J Interprof Care 2003;17:127-39. https://doi.org/10.1080/1356182031000081731.
42. Sheaff R, Lloyd-Kendall A. Principal-agent relationships in general practice: the first wave of English Personal Medical Services pilot contracts. J Health Serv Res Policy 2000;5:156-63. https://doi.org/10.1177/135581960000500306.
43. Royal College of General Practitioners . The Curriculum Topic Guides 2019.
44. Jacobs S. Addressing the problems associated with general practitioners’ workload in nursing and residential homes: findings from a qualitative study. Br J Gen Pract 2003;53:113-19.
45. Corroon-Sweeney E, Murphy C, Collins DR. Caring for nursing home patients – a primary care perspective. Ir Med J 2009;102:317-20.
46. Gleeson LE, Jennings S, Gavin R, McConaghy D, Collins DR. Primary care in nursing homes revisited: survey of the experiences of primary care physicians. Ir Med J 2014;107:234-6.
47. Barker RO, Craig D, Spiers G, Kunonga P, Hanratty B. Who should deliver primary care in long-term care facilities to optimize resident outcomes? A systematic review. J Am Med Dir Assoc 2018;19:1069-79. https://doi.org/10.1016/j.jamda.2018.07.006.
48. Chadborn NH, Devi R, Hinsliff-Smith K, Banerjee J, Gordon AL. Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes. Eur Geriatr Med 2021;12:17-26. https://doi.org/10.1007/s41999-020-00389-w.
49. Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing 2004;33:612-17. https://doi.org/10.1093/ageing/afh213.
50. Kezirian AC, McGregor MJ, Stead U, Sakaluk T, Spring B, Turgeon S, et al. Advance care planning in the nursing home setting: a practice improvement evaluation. J Soc Work End Life Palliat Care 2018;14:328-45. https://doi.org/10.1080/15524256.2018.1547673.
51. National Association of Primary Care, Association of Directors of Adult Social Services . Primary Care Home and Social Care: Working Together 2018.
52. National Association of Primary Care . Primary Care Home 2020 2019.
53. Sherlaw-Johnson C, Crump H, Curry N, Paddison C, Meaker R. Transforming Health Care in Nursing Homes. An Evaluation of a Dedicated Primary Care Service in Outer East London. London: Nuffield Trust; 2018.
54. Scottish Government . General Medical Services Contract in Scotland 2017.
55. Jokanovic N, Jamsen KM, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and variability in medications contributing to polypharmacy in long-term care facilities. Drugs Real World Outcomes 2017;4:235-45. https://doi.org/10.1007/s40801-017-0121-x.
56. Patterson SM, Hughes CM, Crealey G, Cardwell C, Lapane KL. An evaluation of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study). J Am Geriatr Soc 2010;58:44-53. https://doi.org/10.1111/j.1532-5415.2009.02617.x.
57. Molloy DW, Guyatt GH, Russo R, Goeree R, O’Brien BJ, Bédard M, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA 2000;283:1437-44. https://doi.org/10.1001/jama.283.11.1437.
58. Garden G, Green S, Pieniak S, Gladman J. The Bromhead Care Home Service: the impact of a service for care home residents with dementia on hospital admission and dying in preferred place of care. Clin Med 2016;16:114-18. https://doi.org/10.7861/clinmedicine.16-2-114.
59. Sharp T, Malyon A, Barclay S. GPs’ perceptions of advance care planning with frail and older people: a qualitative study. Br J Gen Pract 2018;68:e44-53. https://doi.org/10.3399/bjgp17X694145.
60. Brighton LJ, Selman LE, Gough N, Nadicksbernd JJ, Bristowe K, Millington-Sanders C, et al. ‘Difficult Conversations’: evaluation of multiprofessional training. BMJ Support Palliat Care 2018;8:45-8. https://doi.org/10.1136/bmjspcare-2017-001447.
61. Badger F, Plumridge G, Hewison A, Shaw KL, Thomas K, Clifford C. An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation. Int J Nurs Stud 2012;49:586-95. https://doi.org/10.1016/j.ijnurstu.2011.10.021.
62. Royal College of General Practitioners (RCGP) . RCGP Framework to Support the Governance of General Practitioners With Extended Roles 2020.
63. Gérvas J, Starfield B, Violán C, Minué S. GPs with special interests: unanswered questions. Br J Gen Pract 2007;57:912-17. https://doi.org/10.3399/096016407782317865.
64. Fisher RF, Croxson CH, Ashdown HF, Hobbs FR. GP views on strategies to cope with increasing workload: a qualitative interview study. Br J Gen Pract 2017;67:e148-156. https://doi.org/10.3399/bjgp17X688861.
65. Elvey R, Bailey S, Checkland K, McBride A, Parkin S, Rothwell K, et al. Implementing new care models: learning from the Greater Manchester demonstrator pilot experience. BMC Fam Pract 2018;19. https://doi.org/10.1186/s12875-018-0773-y.
66. Iliffe S, Davies N, Manthorpe J, Crome P, Ahmedzai SH, Vernooij-Dassen M, et al. Improving palliative care in selected settings in England using quality indicators: a realist evaluation. BMC Palliat Care 2016;15. https://doi.org/10.1186/s12904-016-0144-1.
67. Amador S, Goodman C, Mathie E, Nicholson C. Evaluation of an organisational intervention to promote integrated working between health services and care homes in the delivery of end-of-life care for people with dementia: understanding the change process using a social identity approach. Int J Integr Care 2016;16. https://doi.org/10.5334/ijic.2426.
68. Evans G. Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice-based audit. J Eval Clin Pract 2011;17:1045-9. https://doi.org/10.1111/j.1365-2753.2010.01471.x.
69. Stocker R, Bamford C, Brittain K, Duncan R, Moffatt S, Robinson L, et al. Care home services at the vanguard: a qualitative study exploring stakeholder views on the development and evaluation of novel, integrated approaches to enhancing healthcare in care homes. BMJ Open 2018;8. https://doi.org/10.1136/bmjopen-2017-017419.
70. Szczepura A, Wild D, Khan AJ, Owen DW, Palmer T, Muhammad T, et al. Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period. BMJ Open 2016;6. https://doi.org/10.1136/bmjopen-2015-009882.
71. Patterson SM, Hughes CM, Cardwell C, Lapane KL, Murray AM, Crealey GE. A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland study): a cost-effectiveness analysis. J Am Geriatr Soc 2011;59:586-93. https://doi.org/10.1111/j.1532-5415.2011.03354.x.
72. Hughes CM, Patterson S, Schweizer A. Information is care: the need for data to assess the quality of care in UK nursing and residential homes. Expert Opin Drug Saf 2003;2:523-7. https://doi.org/10.1517/14740338.2.6.523.
73. Ballard C, Powell I, James I, Reichelt K, Myint P, Potkins D, et al. Can psychiatric liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities. Int J Geriatr Psychiatry 2002;17:140-5. https://doi.org/10.1002/gps.543.
74. Khunti K, Kinsella B. Effect of systematic review of medication by general practitioner on drug consumption among nursing-home residents. Age Ageing 2000;29:451-3. https://doi.org/10.1093/ageing/29.5.451.
75. Ballard C, Orrell M, YongZhong S, Moniz-Cook E, Stafford J, Whittaker R, et al. Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) Program. Am J Psychiatry 2016;173:252-62. https://doi.org/10.1176/appi.ajp.2015.15010130.
76. Ballard C, Corbett A, Orrell M, Williams G, Moniz-Cook E, Romeo R, et al. Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster-randomised controlled trial. PLOS Med 2018;15. https://doi.org/10.1371/journal.pmed.1002500.
77. Ballard C, Orrell M, Moniz-Cook M, Woods R, Whitaker R, Corbett A, et al. Improving mental health and reducing antipsychotic use in people with dementia in care homes: the WHELD research programme including two RCTs. Programme Grants Appl Res 2020;8. https://doi.org/10.3310/pgfar08060.
78. The Health Foundation . Medication Review Project: An Interview With Project Lead, Dr Wasim Baqir n.d. www.health.org.uk/article/medication-review-project-an-interview-with-project-lead-dr-wasim-baqir (accessed 25 August 2021).
79. Baqir W. Improving Medicine Prescribing in Care Homes. London: The Health Foundation; 2013.
80. Baqir W. Multidisciplinary Review of Medication in Nursing Homes: A Clinico-Ethical Framework. London: The Health Foundation; 2018.
81. Northumbria Healthcare NHS Foundation Trust . Shine 2012 Final Report. A Clinico-Ethical Framework For Multidisciplinary Review of Medication in Nursing Homes 2014. www.health.org.uk/sites/default/files/Shine2012_NorthumbriaHealthcareNHSFoundationTrust_report.pdf (accessed 25 August 2021).
82. Baqir W, Barrett S, Desai N, Copeland R, Hughs J. A clinico-ethical framework for multidisciplinary review of medication in nursing homes. BMJ Qual Improv Rep 2014;3. https://doi.org/10.1136/bmjquality.u203261.w2538.
83. Baqir W, Barrett S, Hughes J, Desai N, Riddle J, Laverty A, et al. A clinico-ethical framework for multidisciplinary review of medication in nursing homes: a Health Foundation Shine project. Int J Pharm Pract 2013;21. https://doi.org/10.1111/ijpp.12064.
84. Baqir W, Hughes J, Jones T, Barrett S, Desai N, Copeland R, et al. Impact of medication review, within a shared decision-making framework, on deprescribing in people living in care homes. Eur J Hosp Pharm 2017;24:30-3. https://doi.org/10.1136/ejhpharm-2016-000900.
85. Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, et al. Clinical medication review by a pharmacist of elderly people living in care homes – randomised controlled trial. Age Ageing 2006;35:586-91. https://doi.org/10.1093/ageing/afl075.
86. Bond C, Lane K, Poland F, Maskrey V, Blyth A, Desborough J, et al. GP views on the potential role for pharmacist independent prescribers within care homes: Care Homes Independent Pharmacist Prescribing Study (CHIPPS): ‘There has to be something in it for me’. Int J Pharm Pract 2016;24. https://doi.org/10.1111/ijpp.12258.
87. Inch J, Notman F, Bond CM, Alldred DP, Arthur A, Blyth A, et al. The Care Home Independent Prescribing Pharmacist Study (CHIPPS) – a non-randomised feasibility study of independent pharmacist prescribing in care homes. Pilot Feasibility Stud 2019;5. https://doi.org/10.1186/s40814-019-0465-y.
88. Badger F, Clifford C, Hewison A, Thomas K. An evaluation of the implementation of a programme to improve end-of-life care in nursing homes. Palliat Med 2009;23:502-11. https://doi.org/10.1177/0269216309105893.
89. Hall S, Goddard C, Stewart F, Higginson IJ. Implementing a quality improvement programme in palliative care in care homes: a qualitative study. BMC Geriatr 2011;11. https://doi.org/10.1186/1471-2318-11-31.
90. Kinley J, Hockley J, Stone L, Dewey M, Hansford P, Stewart R, et al. The provision of care for residents dying in UK nursing care homes. Age Ageing 2014;43:375-9. https://doi.org/10.1093/ageing/aft158.
91. Stewart K, Hargreaves C, Jasper R, Challis D, Tucker S, Wilberforce M. Provision and perceived quality of mental health services for older care home residents in England: a national survey. Int J Geriatr Psychiatry 2018;33:364-70. https://doi.org/10.1002/gps.4753.
92. Madigan SM, Fleming P, Wright ME, Stevenson M, Macauley D. A cluster randomised controlled trial of a nutrition education intervention in the community. J Hum Nutr Diet 2014;27:12-20. https://doi.org/10.1111/jhn.12079.
93. Sadler E, Porat T, Marshall I, Hoang U, Curcin V, Wolfe CDA, et al. Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement. PLOS ONE 2017;12. https://doi.org/10.1371/journal.pone.0177102.
94. Shah SM, Carey IM, Harris T, Dewilde S, Cook DG. Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study. BMJ 2011;342. https://doi.org/10.1136/bmj.d912.
95. Cox H, Puffer S, Morton V, Cooper C, Hodson J, Masud T, et al. Educating nursing home staff on fracture prevention: a cluster randomised trial. Age Ageing 2008;37:167-72. https://doi.org/10.1093/ageing/afm168.
96. Kinley J, Stone L, Dewey M, Levy J, Stewart R, McCrone P, et al. The effect of using high facilitation when implementing the Gold Standards Framework in Care Homes programme: a cluster randomised controlled trial. Palliat Med 2014;28:1099-109. https://doi.org/10.1177/0269216314539785.
97. Killick S, Pharaoh A, Randall F. Advance care planning in care homes. Palliat Med 2010;24:445-6. https://doi.org/10.1177/0269216310366748.
98. Badger FJ, Shaw KL, Hewison A, Clifford C, Thomas K. Gold Standards Framework in Care Homes and advance care planning. Palliat Med 2010;24. https://doi.org/10.1177/0269216310366606.
99. National Institute for Health and Care Excellence . Medicines Management in Care Homes. Quality Standard [QS85] 2015. www.nice.org.uk/guidance/qs85 (accessed 24 August 2021).
100. Coleman A, Croke S, Checkland K. Improving care in care homes: what can primary care networks learn from the vanguards?. J Integr Care 2020;29:85-96. https://doi.org/10.1108/JICA-06-2020-0037.
101. Ballard C, Orrell M, Sun Y, Moniz-Cook E, Stafford J, Whitaker R, et al. Impact of antipsychotic review and non-pharmacological intervention on health-related quality of life in people with dementia living in care homes: WHELD – a factorial cluster randomised controlled trial. Int J Geriatr Psychiatry 2017;32:1094-103. https://doi.org/10.1002/gps.4572.
102. National Institute for Health and Care Excellence (NICE) . Antipsychotics in People Living With Dementia 2015.
103. Ballard C, Corbett A. Reducing psychotropic drug use in people with dementia living in nursing homes. Int Psychogeriatr 2020;32:291-4. https://doi.org/10.1017/S1041610219001455.
104. Chadborn NH, Goodman C, Zubair M, Sousa L, Gladman JRF, Dening T, et al. Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review. BMJ Open 2019;9. https://doi.org/10.1136/bmjopen-2018-026921.
105. Bunn F, Goodman C, Corazzini K, Sharpe R, Handley M, Lynch J, et al. Setting priorities to inform assessment of care homes’ readiness to participate in healthcare innovation: a systematic mapping review and consensus process. Int J Environ Res Public Health 2020;17. https://doi.org/10.3390/ijerph17030987.
106. Keenan J, Poland F, Manthorpe J, Hart C, Moniz-Cook E. Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: a process evaluation of the ResCare study using normalisation process theory. Dementia 2020;19:1604-20. https://doi.org/10.1177/1471301218803195.
107. Owen T, Meyer J. My Home Life: Promoting Quality of Life in Care Homes. York: Joseph Rowntree Foundation; 2012.
108. Hanratty B, Burton JK, Goodman C, Gordon AL, Spilsbury K. Covid-19 and lack of linked datasets for care homes: the pandemic has shed harsh light on the need for a live minimum dataset. BMJ 2020;369. https://doi.org/10.1136/bmj.m2463.
109. Burton JK, Goodman C, Guthrie B, Gordon AL, Hanratty B, Quinn TJ. Closing the UK care home data gap – methodological challenges and solutions. Int J Popul Data Sci 2021;5. https://doi.org/10.23889/ijpds.v5i4.1391.
110. Darby J, Horne J, Lewin J, Crocker C, Coates E, McEwan K, et al. Benchmarking the Prevalence of Care Problems in UK Care Homes Using the LPZ-I: A Feasibility Study 2017. https://nottingham-repository.worktribe.com/output/853694/benchmarking-the-prevalence-of-care-problems-in-uk-care-homes-using-the-lpz-i-a-feasibility-study (accessed 25 August 2021).
111. Musa MK, Akdur G, Hanratty B, Kelly S, Gordon A, Peryer G, et al. Uptake and use of a minimum data set (MDS) for older people living and dying in care homes in England: a realist review protocol. BMJ Open 2020;10. https://doi.org/10.1136/bmjopen-2020-040397.
112. The Health Foundation, Northumbria Healthcare NHS Foundation Trust . Shine – Multidisciplinary Review of Medication in Nursing Homes 2018. www.sps.nhs.uk/articles/shine-multidisciplinary-review-of-medication-in-nursing-homes-christine-randall/ (accessed 25 August 2021).

Appendix 1 Theory-gleaning interview schedule

• Describe the variety of general practice and care home structures.

  • Can you describe the GP–care home ‘link’ [i.e. the working relationship and communication between GP and care home (manager)]?

  • Is it helpful to characterise or categorise different care homes or different types of partnership (GP/care home)?

• How do GPs work with teams outside their jurisdiction? For example, out-of-hours care?

  • Is it similar to the working relationship and communication with the care home, but this time with another team delivering care to the GP’s patients?

• How do GPs support ‘holistic care’ when aspects may be outside the medical remit of the GP?

  • Within person-centred care or multidisciplinary care, are there aspects that the GP may leave to other practitioners or providers (e.g. social or occupational care) or does the GP take an interest in the oversight of all aspects of care?

• Please describe medical teaching or training.

  • How are trainee GPs supported in learning how to deliver high-quality care for care home residents?

  • Are there particular aspects where additional training is available or recommended for GPs?

• Please describe cross-cutting resources and capacity.

  • Is lack of resource a constraint in the above topics?

• What outcomes are expected or assessed?

  • Well-being, quality of life?

  • Service use, such as hospital admissions?

• What information technology systems are used?

  • Are these integral to projects or additional ‘extras’?

• Is there anything that I’ve missed or do you have any additional comments?

Appendix 2 Search strategies

Appendix 3 Search results

Appendix 4 Data extraction fields

Appendix 5 Analysis of excerpts from references and quotations from interviews

Appendix 6 The RAMESES checklist

Glossary

Advance care plan

A document describing an individual’s wishes and priorities for treatment as they approach the end of life.

British Medical Association

A professional body for general practitioners.

Care home

Care home includes both residential and care homes with on-site nursing (international terms include long-term care facility, residential care facility and skilled nursing facility).

Care Quality Commission

The regulator for health care and social care services in England.

Clinical Commissioning Group

A NHS organisation with responsibility for a local population that plans, arranges and funds health services. Individual general practitioners are also members of these organisations.

Context–mechanism–outcome

A summary statement of realist programme theory.

Direct Enhanced Services contract

A national contract for general practitioners to provide services in addition to a General Medical Services contract.

Enhanced Health in Care Homes

A NHS England framework that sets out requirements for the co-ordination of health care with care homes.

General Medical Services contract

The standard contract for general practitioners to deliver care to all their registered patients.

Gold Standard Framework for Care Homes

A programme of training and accreditation in end-of-life care for care home staff, which was built on the established Gold Standard Framework in general practice.

Locally Enhanced Services contract

A local contract for general practitioners to provide services in addition to the General Medical Services contract (e.g. additional services to care homes).

Optimal

A realist evaluation involving realist review and case studies of the different ways primary care services worked with care homes to build a theory of what supports integrated working between NHS and long-term care.

Personal Medical Services

A voluntary option for general practitioners to enter into locally negotiated contracts. The scheme applies to general practices in England only. It enables innovative and flexible ways of working in primary care, a greater skill mix and a team-based approach to managing patients, and can provide a general practitioner-salaried option contract.

ProactivE heAlthcare for older people living in Care Homes

A research programme in which quality improvement collaboratives were studies in care homes across four sites.

Quality and Outcomes Framework

A performance management and payment system of general practitioners (part of the General Medical Services contract in April 2004).

Quality improvement

A set of techniques of change management within a broader concept of ‘improvement’.

Realist And Meta-narrative Evidence Syntheses: Evolving Standards

Reporting guidelines for realist reviews.

Royal College of General Practitioners

A professional body for general practitioners.

Shine

A programme of quality improvement funded by The Health Foundation (London, UK), including a pharmacist-led medication review quality-improvement programme in Northumbria, UK.

Vanguard

A NHS England programme piloting integrated care or new models of care. One element of the scheme involved care homes.

Wellbeing and Health for People with Dementia

A programme of research to develop and test a social interaction intervention to support de-prescribing of antipsychotic medication in care homes.

List of abbreviations

ACP

advance care plan

ASSIA

Applied Social Sciences Index and Abstracts

CINAHL

Cumulative Index to Nursing and Allied Health Literature

CMO

context–mechanism–outcome

EHCH

Enhanced Health in Care Homes

GP

general practitioner

GSF

Gold Standards Framework

GSF-CH

Gold Standard Framework for Care Homes

MDT

multidisciplinary team

PEACH

ProactivE heAlthcare for older people living in Care Homes

PPI

patient and public involvement

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

QI

quality improvement

RAMESES

Realist And Meta-narrative Evidence Syntheses: Evolving Standards

WHELD

Wellbeing and Health for People with Dementia

Notes

1. Context expert group presentation 1

2. Context expert group presentation 2

Supplementary material can be found on the NIHR Journals Library report page (https://doi.org/10.3310/hsdr09200).

Supplementary material has been provided by the authors to support the report and any files provided at submission will have been seen by peer reviewers, but not extensively reviewed. Any supplementary material provided at a later stage in the process may not have been peer reviewed.