Health professionals’ views of the first national GP payment scheme for structured type 2 diabetes care in Ireland: a qualitative study

Setting

This study was carried out as part of an evaluation of the NCPD⁴². The NCPD was established in Ireland in 2010 to standardise and improve care for people with diabetes. By resourcing the management of people with uncomplicated T2DM in general practice, the cycle of care facilitated part of the model of integrated care for diabetes introduced by the NCPD^43–45.

Due to the absence of a GP register in Ireland, the exact proportion of GP practices enrolled in the cycle of care is not known.

Participants and sampling

Data were drawn from a multiple case study designed to evaluate the implementation of the NCPD⁴². Cases were administrative regions within the Irish health service, and health professionals in hospital and primary care settings from each case were interviewed⁴². For the current analysis, transcripts from health professionals specifically involved in primary care diabetes management (GPs, practice nurses and community diabetes nurse specialists (DNS)) and who referenced the cycle of care were included. As evaluating the role of the DNS was a specific objective of the NCPD evaluation⁴², DNS were overrepresented in the study compared to GPs and practice nurses.

Data collection

Interviews and focus groups were conducted by two health services researchers (FR and KON) with no experience of working within the health service. Data were collected from April 2016 to June 2017, approximately 6 months after the introduction of the cycle of care. Topic guides included questions about the impact of the cycle of care on participants’ role, on their patients and on T2DM care in general, and perceived strengths and limitations associated with it (extended data files 2 and 3)⁴¹. The topic guides were piloted with one GP, one practice nurse and two DNS. Questions relating to the cycle of care did not change after piloting.

Data analysis

Qualitative software NVivo (version 11) was used for data management. NMG used the search function in NVivo to identify all references to the cycle of care from eligible participant transcripts and collated these data in NVivo for analysis (n=28 participants). We adopted an inductive approach to analysis, following the iterative phases of reflexive thematic analysis. This approach facilitated description of participants’ experiences of implementing the cycle of care, without imposing any pre-existing, theoretically informed codes^46,47. During familiarisation, the data were read carefully to identify and code meaningful units of text relevant to the research question (NMG). The codes and data excerpts were collated and reviewed to develop themes (NMG). Themes were then refined through discussion (NMG, FR and SMH) and with reference to the data. Anonymised participant quotations presented in the analysis to illustrate qualitative findings maintain the language of participants to preserve meaning and context.

The Standards for Reporting Qualitative Research (SRQR) statement informed reporting of the manuscript^41,48.

Ethical considerations

Ethical approval was obtained from the Clinical Research Ethics Committee for the Cork Teaching Hospitals (CREC) for the original study, including reuse of the original study data for the current study.

Improved financial viability for T2DM care in GP practices

Most participants perceived the cycle of care payment positively in terms of its impact on T2DM care. Participants believed it encouraged GP practices to start providing structured T2DM management for the first time because it was more financially viable to do so in general practice. For instance, one DNS explained that prior to the cycle of care, “financially it didn’t make sense for [GP practices] to be looking after chronic disease such as diabetes” (DNS #9), unless GP practices were part of structured diabetes schemes with dedicated resourcing. For GP practices providing T2DM care without specific resources from structured diabetes schemes, the cycle of care was an overdue “fundamental support” (GP #1) as costs to provide T2DM care (e.g., hiring extra nurses), were previously paid for by the GP practice. With the removal or reduction of a financial barrier, participants believed that T2DM management was financially viable for more GP practices.

Moving from reactive to proactive T2DM care

For GP practices providing opportunistic care, the register and recall system and structured review visits required within the cycle of care facilitated a more organised approach to T2DM management.

The register and recall system encouraged GP practices to schedule and remind patients to attend diabetes appointments. Participants believed the register and recall system increased the number of patients attending appointments and reduced the likelihood that patients would “fall through the cracks” (GP #3). In this way, GP practices could identify and track patients with different levels of need;

The “tick-box” (Practice nurses #1, #4) structure of the review visit form was considered helpful to prompt nurses about topics to be covered and the comprehensive list of care processes it required meant issues could be identified earlier;

Taken together, the register and recall system and structured visit form were thought to lead to improved patient outcomes.

Increased demand for other diabetes services

Participants perceived increased demand for the DNS service, for retinal screening and for podiatry services as a result of the cycle of care.

Practice nurses working in GP practices providing structured T2DM care for the first time, through the cycle of care, reported drawing on the DNS service to support them to establish the registration and recall processes within the GP practice and to review patients that were more complex. DNS viewed the increased service demand as a positive consequence of the cycle of care, as it enabled them to fulfil their role supporting practice nurses in T2DM management. However, some DNS expressed concern about the potential inappropriate use of their service. Specifically, some DNS did not want to complete routine cycle of care review visits alongside practice nurses as they felt review of people with uncomplicated T2DM was not the best use of their specialist input.

Care closer to home; a positive change for (most) patients

Another perceived benefit of the cycle of care was the proximity of care for eligible patients. Participants felt most patients would prefer to receive T2DM care at their GP practice, given this would be more convenient than attending the hospital, especially for older persons or those living in rural areas. Participants felt that the greater focus on T2DM by GP practices encouraged patients to better prioritise, and engage with, their T2DM care;

However, some DNS participants encountered patients who were sceptical about switching to GP care. For instance, one DNS suggested that certain patients may perceive the two visits in general practice as a “hassle” (DNS #1), particularly if they have been accustomed to fewer diabetes review visits in the past.

Structured review visits; demanding to deliver without more resources

All participants highlighted the significant workload for GP practices associated with maintaining the register and completing review visits. Completing the cycle of care review visit protocol as intended was “time-consuming” (Practice nurses #2, #7, GP #5, DNS #10) with protected practice nurse time, and even more challenging without this. For instance, in two GP practices with 150 and 200 patients registered for the cycle of care, respectively, the workload was described as almost being a full-time job for one practice nurse.

Practice nurses used workarounds to manage the additional workload, for example, adding more hours to the time allocated for diabetic clinics, and splitting up the protocol, completing it during an extra visit. Two GP practices had hired an additional practice nurse to assist with chronic disease management, particularly the cycle of care.

Ultimately participants felt “it’s [cycle of care] not adequately funded for the GP…all resources cost” (GP #4).

Two visits; too rigid to adequately meet patients’ needs

Some participants, particularly those already providing structured T2DM care, expressed concern about the rigidity of the two review visits specified and remunerated as part of the cycle of care. Because these visits had to occur six months apart, they did not provide enough contact to meet the needs of certain patients e.g., those starting on insulin, requiring medication changes or with poorly controlled T2DM. As a result, GP practices provided more diabetes interactions than set out in the cycle of care, for which they were not remunerated. Participants working in GP practices who had previously provided T2DM care according to need i.e., seeing some people more than twice annually and others just once, expressed frustration having to review well-controlled patients who they would otherwise have not prioritised.

One way participants suggested addressing the rigidity of the cycle of care was to strike a balance between remuneration for processes and outcomes of care. For instance, one GP suggested “some kind of a step-up contract” (GP #2) to resource the GP to provide more than two structured diabetes review visits where appropriate e.g., for poorly controlled diabetes and for insulin initiation. A DNS expressed concern about the financing model, stating,

Eligibility criteria; creating inequity in access to care

Participants who discussed the eligibility criteria considered it to be a fundamental limitation of the cycle of care, asserting that all T2DM patients, regardless of age or financial means, should be eligible. Participants expressed concern that those who are ineligible for the cycle of care could be at higher risk for missing care and subsequently developing complications. Due to time constraints and the remuneration associated with the cycle of care, GP practices prioritised cycle of care visits, particularly in practices without protected nurse time. For instance, one practice nurse noted “Our private [non-eligible patient] care would be worse because, just from time constraints, I haven’t had the time to…make sure that they’ve all had visits” (Practice nurse #3). It was felt that such patients may prefer to keep receiving their diabetes care in hospital settings where they do not have to pay.

Absence of IT systems to return data to receive remuneration

Many participants mentioned returning the associated data as a challenge to implementing the cycle of care. Data return was a criterion for GP practice reimbursement but at the time of data collection there was no system in place to facilitate the return of the cycle of care data. This meant that one year into the rollout of the scheme GP practices were experiencing delays returning data and some had not received reimbursement for cycle of care visits. Participants who discussed this issue attributed the delays to the General Data Protection Regulation and concerns about patient consent. GP and practice nurse participants were concerned about the significant time burden associated with entering data once the data return issues were resolved and one DNS estimated half of the GP practices she attends had not started calling people for review visits due to the perceived data return issues. The time burden of data return was particularly troubling for one nurse working in a non-computerised practice.

Implications

The findings have three important implications relevant for the implementation of GP payment schemes for chronic disease management in Ireland and other health systems. First, some implementation issues identified in this study, such as practice nurse workload and inflexibility to provide care on the basis of need, may be addressed through incorporating protected practice nurse time into future schemes. While the new Chronic Disease Management Programme resources practice nurse time⁵⁰, the level of resourcing should be sufficient to ensure that non-incentivised care is not diminished²⁸.

Secondly, our findings point to the potential implications of the cycle of care eligibility criteria. In the current study, health professionals were concerned that those not eligible for the cycle of care could continue to receive T2DM care in secondary care settings to avoid paying for care in general practice, or would continue to receive opportunistic care in general practice. These perceived consequences, alongside evidence of adverse effects of GP payment schemes on non-incentivised activities^21,27,28,51, underscore the need to assess the impact of the new Chronic Disease Management Programme among those eligible and ineligible for it³⁹.

A final implication relates to staff training needs and demand for specialist services. Training in elements of pay-for-performance schemes, particularly on IT systems and payment mechanisms, have previously been identified as an important modifiable factor in the roll out of payment schemes³³. Although not formally part of the cycle of care, the DNS played a key role in supporting its implementation by providing education and support for practices to establish structured T2DM care visits. In addition, the cycle of care created more demand for the DNS and other community diabetes services through identifying more patients in need of the services. As such, the nature and level of support required to implement the Chronic Disease Management Programme within GP practices in Ireland, and the potential knock-on effect on ancillary services, need to be considered.

Strengths and limitations

This study provides a detailed account of the cycle of care, the first national GP practice payment scheme for T2DM care in Ireland. A strength of the study was the sampling strategy, which included participants across different diabetes care organisational contexts prior to cycle of care adoption⁴². This facilitated an understanding of which aspects of the scheme work, in what context, and for whom.

However, we did not capture the views of all relevant stakeholders, such as people with T2DM or staff working in GP practices who had not adopted the scheme. Exploring the experiences of people with T2DM could provide additional insight into how the cycle of care does or does not work from their perspective. Although one GP in our sample was unaware of the cycle of care and therefore had not signed up to it, participants were not purposively sampled on this criterion. A study specifically designed to explore the implementation of the cycle of care, rather than diabetes reform in general, would have sampled participants according to more specific criteria and principles and thus have facilitated more in-depth exploration of the topic⁵². Future research should seek to understand factors influencing non-adoption of incentive schemes.

Underlying data

Interview and focus group transcripts used in this analysis are unavailable in a data repository as participant consent was only obtained for data analysis by members of the research team. The data can be accessed upon reasonable request from Professor Patricia M Kearney (patricia.kearney@ucc.ie).

Extended data

Open Science Framework: National Clinical Programme for Diabetes evaluation. https://doi.org/10.17605/OSF.IO/8QV24⁴¹

This project contains the following extended data:

Reporting guidelines

Open Science Framework: 'Extended_data_file_4', https://doi.org/10.17605/OSF.IO/8QV24

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).