Prompted choice questionnaire
Of the 12 recruited, 10 clinical staff completed prompted choice on more than one occasion in their consultations. Two GPs did not conduct prompted choice on any occasion, nor did they complete any form of data collection. A total of 10 144 consultations were conducted during the 3-month period, 6569 face-to-face consultations, and 3575 telephone consultations. Prompted choice was conducted by staff in none of the telephone consultations, and in 812 (12.4%) of all face-to-face consultations conducted by participating staff members. Doctors conducted prompted choice on 46 out of 2875 face-to-face consultations (1.6%), nurses on 472 occasions out of 2014 face-to-face consultations (23.4%), and healthcare assistants on 296 occasions out of 1734 face-to-face consultations (17.1%).
Of the 812 patients asked, 244 joined the NHS ODR (30.0%). Table 1 shows the full breakdown of patient responses to prompted choice. Based on the responses in Table 1, 352 patients (43.3% of those asked) were added to the NHS ODR for the first or second time (by wishing to re-register) as a result of the intervention.
Table 1. A breakdown of patient responses to prompted choice and reasons why prompted choice was not conducted
Prompted choice reached 187 black, asian and minority ethnic (BAME) patients, and 326 non-BAME patients. Of these patients, 39 BAME patients joined the NHS ODR for the first time, 20.9% of those asked. Ethnicity was not specified for 299 patients who received prompted choice. The average age of patients targeted was 50.2 years (with a standard deviation of 17.6, a minimum of 18, a maximum of 91, a median of 50, and a mode of 67 years).
Prompted choice feasibility questionnaire
The feasibility questionnaire was completed 2906 times, and, on 134 occasions, only partially completed. During face-to-face consultations, a feasibility questionnaire was completed 1690 times, and, on 1051 occasions, prompted choice was stated not to be conducted due to a telephone consultation. Lack of time was stated as the reason for not conducting prompted choice on 34.0% (n = 943) of feasibility questionnaires and not appropriate for consultation on 18.8% (n = 520) questionnaires. On 43 occasions, a language barrier was specified, and other reasons were suggested on less than 10 occasions each (for example, data entry error, home visit, lack of capacity, or over eligible age limit).
Staff focus groups and online survey
External contextual factors were less prominent in the focus groups discussions, and only once was the opt-out policy mentioned by staff. Predominantly, staff discussed GP settings generally, media exposure to organ donation, registration through the Driving Vehicle Licensing Agency, and that organ donation is not a normal thing to discuss in society:
‘In the general world of general practice, we’ve got the knowledge and the expertise, and, especially with a little bit of training, I think that’s fine.’
(Focus group [FG], GP)
‘Well, normally it’s a no-no, you don’t talk about things like that, do you?’
(FG, administrative and reception)
At the organisation contextual level, staff discussed that they could not conduct prompted choice during telephone consultations, that it was easier to conduct prompted choice with weekend patients (patients who attend the GP practice at the weekend, that is, those who are more likely to work Monday to Friday), that there is a culture of collaboration and prioritising patient care in the practice, and that some consultations were more suitable for conducting prompted choice than in others. This latter theme was strong throughout, as those clinics that are ‘routine’, for example, phlebotomy or practice nurse sessions, were more suitable for prompted choice. Clinics where the patient could present with a serious issue, particularly those conducted by GPs, as well as those where nurses did not know why patients were visiting, were more challenging:
‘You’ve got to listen to the patient, you’ve got to examine the patient, you’ve got to figure out what’s wrong, you’ve then got to, you know, prescribe, do the [prescription], then give the advice, so that’s completely different to a practice nurse session ... or maybe even your phlebotomy session.’
(FG, nurse and healthcare assistants)
Professional contextual factors included a wide variety of perspectives around prompted choice. Views among staff were polarised, with some (those who conducted it more often), believing it to be very acceptable and easy to conduct, and others (those conducting it less often), believing it to be challenging to conduct.
Overall, however, staff had positive attitudes to prompted choice, believing it to be a good idea, and to be congruent with their professional role in most cases.
At the intervention contextual level, lack of time during consultations was the barrier discussed most often, alongside whether it was appropriate to ask all patients, and concerns over negatively impacting the patient relationship:
‘I would be happy to continue asking my patients if intervention was reintroduced as I feel it is a tremendously worthwhile [and] beneficial process to contribute towards.’
(Staff online survey)
‘I still think general practice would probably be the best place for these things to happen and it’s a real shame if we cannot do this.’
(FG, GP)
‘It depends on the patients really … because if they were really ill, I didn’t, I wouldn’t bring it up because I think that’s not appropriate.’
(FG, GP)
‘The time was quite limited [because], you know, like you said, they’ve come in and they want to start telling you what’s wrong.’
(FG, nurse and healthcare assistants)
Staff also reported problems with the SystmONE prompt and questionnaire, mainly that it was too long and complex. Staff had mixed views on the usefulness of leaflets and posters, with some using them to start the prompted choice process, and others believing patients did not read them.
Finally, regarding the IIFF model, providing information as part of prompted choice was discussed by all staff verbally and also through the leaflets, and most staff were comfortable with this. Mixed views were discussed concerning an immediate registration opportunity, with some staff believing it was a good idea, and others that it was better for patients to go away and think about it. Fewer discussions were had on the topic of focused engagement, however, staff mentioned that some patients wanted to start talking about their problem immediately, and then wanted to leave once they were finished, indicating that patients may not have been focused on the topic of organ donation during prompted choice.
Favourable activation, however, was discussed at length, with some staff concerned about patients being distressed by the topic, and it not being appropriate. However, some discussed that they did not have any instances where a patient was distressed.
Patient online survey
Of the 36 patients who completed the online survey, 21 patients were asked by a nurse or healthcare assistant, seven were asked by a doctor or GP, and eight were not asked at all. 12 patients noticed the leaflets and posters displayed in the practice, and 22 patients did not.
Responses to the open questions showed most patients believed the intervention to be acceptable and appropriate in a general practice setting:
‘I went in to have my smear test and was asked at the end. I thought it was a great idea to ask me whilst in the room for a medical reason.’
(Patient Online Survey)
‘As long as asked once and not pressured, I’m not bothered. I am already a donor.’
(Patient Online Survey)
‘This is probably the most appropriate place to be approached.’
(Patient Online Survey)
‘This is the best place for the conversation in my view.’
(Patient Online Survey)
Some patients described that it might be annoying, and one patient described feeling pressured to sign up. Patients, on the whole, did not find the leaflets and posters useful. This was further illustrated by recommendations provided by the patients, including providing leaflets in the waiting rooms when these were already provided.
‘Ok. Its same as being bombarded with tv ads. Annoying.’
(Patient Online Survey)
‘ [Leaflets are] useful as information reminders, but little influence on decision. The major influence for me, on deciding this sort of thing, is speaking with someone.’
(Patient Online Survey)
