Green shoots of recovery: a realist evaluation of a team to support change in general practice

OBJECTIVE A multidisciplinary support team for general practice was established in April 2014 by a local National Health Service (NHS) England management team. This work evaluates the team's effectiveness in supporting and promoting change in its first 2 years, using realist methodology. SETTING Primary care in one area of England. PARTICIPANTS Semistructured interviews were conducted with staff from 14 practices, 3 key senior NHS England personnel and 5 members of the support team. Sampling of practice staff was purposive to include representatives from relevant professional groups. INTERVENTION The team worked with practices to identify areas for change, construct action plans and implement them. While there was no specified timescale for the team's work with practices, it was tailored to each. PRIMARY AND SECONDARY OUTCOME MEASURES In realist evaluations, outcomes are contingent on mechanisms acting in contexts, and both an understanding of how an intervention leads to change in a socially constructed system and the resultant changes are outcomes. RESULTS The principal positive mechanisms leading to change were the support team's expertise and its relationships with practice staff. The 'external view' provided by the team via its corroborative and normalising effects was an important mechanism for increasing morale in some practice contexts. A powerful negative mechanism was related to perceptions of 'being seen as a failing practice' which included expressions of 'shame'. Outcomes for practices as perceived by their staff were better communication, improvements in patients' access to appointments resulting from better clinical and managerial skill mix, and improvements in workload management. CONCLUSIONS The support team promoted change within practices leading to signs of the 'green shoots of recovery' within the time frame of the evaluation. Such interventions need to be tailored and responsive to practices' needs. The team's expertise and relationships between team members and practice staff are central to success.