The role and impact of facilitators in primary care: findings from the implementation of the Gold Standards Framework for palliative care.

BACKGROUND Facilitation is the process of providing support to individuals or groups to achieve beneficial change. It is intrinsic to the Gold Standards Framework (GSF) for palliative care, a programme introduced widely in UK general practices. OBJECTIVES To explore how GSF facilitators fulfil their role and the impact of the facilitators' backgrounds and approach on practices' uptake of the programme. SETTING Primary care organizations and general practices in England and Northern Ireland. METHODS Self-completed questionnaire and semi-structured interviews with facilitators. Practice audit questionnaire. Descriptive statistics. Thematic analysis. Linear and random effects models. RESULTS A total of 102 (59.6%) facilitators completed a questionnaire; interviews were performed with nine facilitators. A large variability was found in the facilitators' professional backgrounds, role setup and activities. The impact of several facilitation characteristics on practice change was modelled for 63 (36.8%) facilitators and 266 practices (20.4%). No evidence was found of an association between practice change and facilitators' specialist knowledge of palliative care, mean facilitation time per practice, mean number of visits, facilitator budget and incentives offered to practices. Facilitators with a GP background were associated with higher levels of GSF change than those with a clinical nurse specialist background (P = 0.0078 with Bonferroni correction, significance threshold for corrected P = 0.008). The interviews indicated that the differential implementation of the framework might have been strongly affected by internal and external practice-related factors that were not readily amenable to facilitation. CONCLUSION This study goes some way towards untangling aspects of facilitation associated with successful implementation of the GSF. Further prospective research and evaluation is needed to identify ways of improving its sustainability, effect on patient outcomes and cost-effectiveness.