Optimising personal continuity in general practice: process evaluation of a toolkit

Personal continuity - having a GP who knows and follows the patient - is a core value of general practice, yet changes in society and health care have challenged its provision. Therefore, we developed TOOL-kit: an intervention to opTimise persOnal cOntinuity for oLder patients in general practice, a multi-component intervention aimed to optimise personal continuity for patients aged ≥65 years.

To evaluate TOOL-kit's implementation and identify barriers and facilitators influencing its delivery.

This mixed-methods study was embedded in the main effect trial (August 2020 to April 2022).

Implementation was assessed via 3-monthly surveys and 93 interviews with GPs and practice staff (n = 221) from 31 general practices. Based on Saunders' paradigm, it was evaluated on the process indicators of recruitment and reach, fidelity (adherence to protocol), dose delivered (extent of improvement plans), and dose received (goal achievement, sustained organisational change). Barriers and facilitators were evaluated on the intervention, staff, organisational, and sociopolitical levels.

Of 31 practices, 23 adhered to protocol. TOOL-kit was delivered at a (very) low dose in 17 of 31 practices. At study end, 55% of practice goals were met. After 24 months, 19 of 31 practices had observed sustained positive effects regarding personal continuity. A good-quality improvement infrastructure facilitated TOOL-kit implementation, while work pressure and staff shortages, exacerbated by COVID-19, were seen as the main barriers for implementation.

Despite implementation challenges, TOOL-kit was able to enhance work procedures and improve the focus on personal continuity within practice. Fostering practices' quality improvement infrastructure and decision-making processes could improve implementation.