Differentiating two types of LWP practices using NPT
The framework analysis identified variation between practices in the implementation and integration of the LWP, which clustered into two distinct groups: fully integrated practices (FIPs), which included three of the seven practices (‘Magenta’, ‘Ochre’, and ‘Cyan’), and partially integrated practices (PIPs), which were the remaining four (‘Crimson’, ‘Cobalt’, ‘Olive’, and ‘Amber’).
The two types of practices did not differ in the number of registered patients on their lists (FIPs mean 4009 [range 2244–5130] versus PIPs mean 4349 [range 2549 to 5946]) nor in the number of patients who were black and minority ethnicity (FIPs mean 7.3%; PIPs mean 7.8%). However, there were fewer training practices in FIPs (one out of three) than PIPs (three out of four).
In FIPs, all aspects of the LWP were implemented and integrated into ways of working so that CLPs were empowered to undertake all aspects of their role — patient support, practice development, and community networking. In PIPs, by the end of the evaluation CLPs were enabled to undertake only some aspects of the LWP. In particular, although CLPs in PIPs did work directly with patients after referral, the practice development and community networking aspects of their work were much less well supported.
For example, in the early stages of the evaluation the authors saw that all practices had tried some activities to enhance staff wellbeing, had explored information systems about the availability of community organisations, and had organised some shared learning sessions for all staff. However, by the end of the evaluation, only FIPs continued these activities. A GP in a FIP reported the benefits of making time for shared learning within the practice:
‘And I think the simple fact of having one afternoon a week where we go off site and we just sit and talk to each other, and have a coffee together, and interact in a more human way, it’s had a real change in the whole dynamic of the practice …’
(Magenta GP, FIP, end-of-evaluation interview, P3)
This view contrasts with that of a CLP in a PIP:
‘Yes, there’s a good rapport and the staff, you know, the administrative staff go out and things. But there is a disconnect between admin staff, and the GP staff. The admin staff as well don’t get team meetings. They don’t get opportunities to come together as a team and share information so communication sometimes can be a bit poor at different times.’
(Cobalt CLP, PIP, end-of-evaluation interview, P3)
The difference between practices was also apparent in relation to community networking activities. Only in FIPs were CLPs enabled to be proactive and strategic, by, for example, making time each week to interact with staff in community organisations, and facilitating links between community organisations and staff in the practice. These activities were highly valued by the CLPs in FIPs:
‘I sit on steering groups in the health centre. Sit on the arts and environmental steering group which is about the health centre and how it’s linking in with regards to arts and, like, so … Then I sit on the community-orientated primary care group, which is across the whole health centre … and it’s about, obviously, community-orientated primary care, linking them in, getting an awareness of what’s going on in the local area.’
(Ochre CLP, FIP, in-depth interview, P3)
In PIPs, however, CLPs reported a more reactive approach to community networking. They were not able to make the time to develop, on an ongoing basis, a more strategic view of what was locally available and needed for different groups in the community. They often reported regret at being unable to do more proactively. For example, the CLP in Cobalt practice felt that she was not doing enough:
‘I would like to be more, I think I would like to be more proactive. Whether that’s possible, like instead of someone coming to me, and me having a conversation with someone and then saying, “Right, OK, let’s look at what’s out there.” What I would quite like to do is to be able to go out and walk around [place name] , or [place name] , or whatever.’
(Cobalt CLP, PIP, end-of-evaluation interview, P3)
Drawing on NPT, Box 3 shows that, compared with staff in PIPs, staff in FIPs had better and more shared understanding of the LWP (coherence), were more likely to engage (cognitive participation), and more likely to work to implement the LWP (collective action). Reflexive monitoring of progress with the LWP, however, was underdeveloped in both types of practice (Box 3). Supplementary Box S3 provides extracts from staff in all seven practices.
| NPT construct | FIPs (three practices) | PIPs (four practices) |
|---|
| Coherence: understanding of the LWP | Core leadership (GP, CLP, and PM) share understanding of the LWP and how they want it to work.
For example, in Cyan practice, the CLP clearly identified why they expected LWP to work:
‘It’s […] trying to build-up knowledge of what is actually out there … So […] part of the programme is for myself to work one to one with people but for the whole practice to be more aware of what [community organisations are] actually around that maybe would support patients and I guess […] try and develop relationships with some of [the staff in] these resources.’ (Cyan CLP, focus group discussion, P1) | Core leadership (GP, CLP, and PM) do not share understanding of the LWP and how they want it to work.
For example, in Cobalt practice, the CLP reported that, although she understood there were three aspects of her job, the lead GP thought the LWP was about being able to refer patients to her (and nothing else):
‘We kept getting told [in training and support] there’s three parts to this job, there’s your one-to-one work [with patients], there’s community building, and there’s practice development. Well if that’s the case, you need to have scope to do all three. You know, and it can’t always be about patients, patients, and patients.’ (Cobalt CLP, in-depth interview, P2) |
| Cognitive participation: staff willing and able to engage with one another to carry out the LWP | Staff engage with each other on the LWP in both formal (meetings and shared learning activities) and informal (over coffee) settings.
For example, in Magenta practice, the CLP was able to work effectively with the whole team to develop the LWP ethos:
‘In terms of attitude, there’s been a huge shift from medical to holistic, where the GPs are seeing beyond the medical presentation and looking at the root core cause, knowing I think, knowing that they have someone to back up their findings, where before they wouldn’t ask certain questions because they couldn’t do anything about it.’ (Magenta CLP, in-depth interview, P2) | Less staff engagement in formal settings (meetings and shared learning activities) and more in informal (over coffee) settings.
For example, in Olive practice, the CLP explains that practice staff have not engaged much and that there are fundamental differences in understanding of the LWP and the CLP’s role:
‘It’s taken our district nurse a year to understand what it is I do and we still sometimes clash on approach and understandings and what that’s about. So, you know, but it’s taken her a year to get to grips. She spent the first year telling everybody I was a psychologist, do you know what I mean?’ (Olive CLP, in-depth interview, P2) |
| Collective action: what staff in practices did to deliver the LWP (focus on work of CLP) | CLP’s role in practice development unconstrained and work balanced across patient support, practice development, and community networking.
For example, in Ochre practice, the CLP explains that the whole practice team now has relationships with community organisations and are confident to liaise on behalf of patients:
‘So say … If the receptionist had booked an appointment at one of the community organisations … They’d [the community organisation] be quite happy if the receptionist calls [to enquire about a referred person] — they can say “Oh, that person didn’t turn up”, and the receptionist might ring the person up and go “Oh … you know, they said that you didn’t turn up. Do you want any support?”… and then they might get referred to me so I can support them, and it’s kinda definitely linking things up. So … Yeah. And I do think it’s really good that the practice staff feel more confident in referring to community organisations.’ (Ochre CLP, in-depth interview, P2) | CLP’s role in practice development constrained; more focus on one-to-one patient support than other activities.
For example, in Amber practice, changes in CLP staff made community networking, a central aspect of the LWP, difficult to maintain. In the first email survey (P2) both the PM and GP noted this. Asked what had been difficult to action:
‘Network building — Too time consuming to allow me to do this. The networking done by our CLP is very helpful. Knowing what resources there are out in the community benefits the team to confidently inform a patient about a service.’ (Amber PM, email survey, P2)
‘Network building — this has been slower to achieve than I first anticipated.’ (Amber GP, email survey, P2) |
| Reflexive monitoring: how staff knew if LWP was effective | Reflexive modelling was underdeveloped in both FIPs and PIPs.
There was no formal monitoring of LWP implementation in any practice. Informal monitoring, based on how people thought ‘things were going’, was used instead.
For example, in Magenta practice, there is not a system to capture information about what is happening in the programme in terms of all the activities and tasks. There is a difficulty with recording activities and monitoring:
‘It’s quite difficult to get it all in because there’s a lot happening. [laughs] And it’s quite hard to sit down and sort of capture all the different elements that are happening to us.’ (Magenta GP, in-depth interview, P2).
But staff can provide feedback at other times (for example, during protected learning times made possible by the LWP), and staff used impressions when asked ‘how they know if the LWP is working’. The Magenta GP said, for example, that they think that patients now know something about how the practice has changed:
‘I get the impression that patients have felt there’s a different feel about the practice. [And noted that] complaints have dropped dramatically.’ (Magenta GP, end-of-evaluation interview, P3) |
Box 3. Comparison of the implementation of the LWP in fully and partially integrated practices based on NPT
Factors influencing the implementation process in the two types of practices
Cross-case comparison between FIPs and PIPs suggested four factors influenced whether or how the LWP was implemented: leadership, team relationships, continuity of CLP support, and the influence of other ongoing interventions.
In FIPs the leadership of the LWP was shared collectively between GPs, CLPs, and practice managers, there were empowering team relationships, continuity of CLP support (or transitions managed well), and no influence from other ongoing innovations. PIPs, on the other hand, had less collective leadership, more challenging team relationships, interrupted CLP support, and in one practice may have been distracted by another ongoing innovation on integration of health and social care.
Data extracts in Box 4 illustrate the findings of the analysis. Supplementary Box S4 provides data extracts from staff in all seven practices.
Leadership was a key factor in how practices implemented LWP. In FIPs, leadership over the LWP was shared among key members of staff — the lead GP, CLP, and PM. A Magenta GP, for example, reflected that others in the practice were also taking on responsibilities:
‘I am continuing to provide leadership but have been pleased to see the wider team taking on roles and for activities such as the learning times to be embedded now in practice activities.’ (Magenta GP, email survey 2, P4)Compared with FIPs, leadership over LWP in PIPs was not as well shared and connected, as indirectly described by the GP of Crimson practice:
‘The programme was designed that they were basically dropped in with no structure, and I totally understand why that was done but it wasn’t easy. That was not easy, either for the Links worker or for us, to create a job from nothing.’ (Crimson GP, in-depth interview, P2)Creating the structure for a new programme to work is the responsibility of practice and LWP leadership, and it appeared to be challenged in Crimson practice.
Team relationships in FIPs were more enabling and positive, which helped with the implementation of the programme, as suggested by the PM in Ochre practice:
‘We’ve done a few team-building events. And I think the positivity from that has been great. I mean, there’s definitely everybody, you know, you know, they feel, everybody feels appreciated.’ (Ochre PM, end-of-evaluation interview, P3)
Team relationships in PIPs on the other hand seemed more challenging and, according to the PM of Olive practice, had a negative impact on programme implementation:
‘Practice staff seem to no longer be interested in the project, relationships seem to have broken down, and apart from the clinical staff there is little or no interest in the project at the moment.’ (Olive PM, email survey 2, P4)
Not all practices experienced disruption of CLP support. However, FIPs that had turnovers in CLP staff appeared to have managed CLP support disruption well. For example, the incoming CLP of Cyan practice was able to ‘shadow’ his predecessor in a handover process, thus ensuring a smoother transition:
‘And then [Outgoing CLP] would brief me on what he’d already done with them [patients] and then we would have a meeting in the GP service clinic with some of the participants and then [Outgoing CLP] would kind of brief me again on where he sees the process going with these participants. So it was a bit of a handover process with some people.’ (Cyan CLP, in-depth interview, P2)
PIPs managed disruption to CLP support less well. Amber practice, for example, was slowed in its LWP implementation when its CLP went on leave:
‘Our CLP is off … As yet we have no idea of when her return will be. We have cover once a week for patient referrals; however, this has changed our momentum with certain capacities.’ (Amber PM, email survey 1, P2)
Not all practices had other ongoing innovations. Two practices that did were, however, PIPs, and the influence of other ongoing interventions appeared to have affected leadership and team relationships. While multiple ongoing interventions in the same setting may not necessarily be a negative factor, in the case of Cobalt practice, for example, it hindered the implementation of LWP because the GP and CLP did not share the same view on how the different interventions might work together:
‘So there’s a wee bit of like when you mention things, he’ll be like, “Oh that’ll be great for the [other project] Project.” And you’re like that, “No … that’s not the [other project] – this is the Links programme.” So yeah, so he has clear ideas in some ways, yeah, he probably does have clear ideas what he wants.’ (Cobalt CLP, in-depth interview, P2) |
Box 4. Examples of how the contextual features of leadership, team relationships, continuity of CLPs’ support, and other innovations influenced LWP integration
