Liver disease as new work in the context of protocolised primary care - Do GPs have a role? A qualitative interview study

Liver disease as new work in the context of protocolised primary care - Do GPs have a role? 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A qualitative interview study Helen Jarvis, Tom Sanders, Barbara Hanratty This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4183178/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Liver disease is common, but not part of routine chronic disease management in primary care. The aim of this study was to explore the challenges of implementing pathways of care for liver disease within existing highly protocolised structures in primary care. Methods Semi-structured interviews with 20 health professionals working in primary care. Interviews were informed by normalisation process theory (NPT) and boundary theory. Data were subject to thematic analysis. Results Three themes were identified relating to chronic disease work; definitions; need and worth, and roles. Participants identified that understanding and value of roles within chronic disease management were pre-defined by targets imposed on them as part of national incentives schemes. Structural boundaries constrained professional autonomy and the potential to influence this area of primary care management, including taking on new work. Discussion The inability to influence care decisions blurs occupational boundaries and goes to the core of what it means to be a professional. Unless liver disease sits within this target-based system, it is unlikely to become part of routine work in primary care. Introduction The organisation of General Practice has changed rapidly over the last 30 years. At the inception of the National Health Service (NHS) in 1948, general medical practitioners (GPs) retained a unique status amongst medical professionals as self-employed individuals. GPs were contracted and funded to provide services to the NHS, with payments primarily based on registered patient numbers. The imposition of the 1990 GP contract was the start of a gradual and persistent shift towards linking GP remuneration to meeting performance targets. Incentivised targets for providing health promotion/prevention and chronic disease management are now an integral part of modern general practice, with continued expansion at both national and local levels of government health policy. Performance targets in these areas have normalised the use of biomedical research evidence summarised in clinical guidelines and protocols, as a core component of good medical practice. This shift from high relative autonomy in practice towards implementation of evidence-based targets has been described by researchers as a fundamental shift in general practice towards a ‘scientific bureaucratic medicine’, 1 with imposed closer linkage to the wider ‘health care state’. 2 As a result of this orientation towards prevention and performance targets, many chronic diseases in UK primary care (particularly the ones incentivised by the Quality Outcomes Framework (QoF) introduced in the General Medical Services (GMS) 2004 contract) 3 are strictly managed in a routine, protocol driven way. This usually consists of an annual chronic disease check, with defined monitoring bloods and observations taken and then interventions enacted, aiming to move any disease parameters within the ‘normal’ or target ranges. Liver disease, mainly due to alcohol related liver disease (ARLD) and/or non-alcohol related fatty liver disease (NAFLD) in the UK, is often chronic in the sense that it requires long term management and modification of known risk factors. Despite this, its management in primary care across the UK is variable with only a minority of areas reporting defined pathways of care for people with liver disease. 4 No liver disease outcomes have ever been part of the QoF or any other national incentivised schemes in primary care health policy. Its importance as a leading cause of premature morbidity and mortality has however been increasingly recognised, with earlier detection and management of liver disease cited in national commissions and guidelines as a key priority. 5,6 The aim of this study was to explore with primary care professionals the challenges of care for a ‘new’ disease - chronic liver disease - being implemented in this protocol driven context. We aimed to study the role that targets, guidelines and incentives have played in chronic disease work, and to analyse how these structural boundaries have influenced the ability of primary care to take on new work and maintain professional roles. Methods Design Thematic analysis of qualitative data obtained through semi-structured interviews with health care professionals (HCP) working in primary care in the North East and North Cumbria (NENC) regions, England. The findings of this study are presented in accordance with the standards for reporting qualitative research. 7 The interviews used for this qualitative analysis have also been used in previous work published by this study team to answer a related but distinct question around the barriers and facilitators to implementing liver disease pathways in primary care. 8 Recruitment Participants were recruited from primary care commissioning networks in the NENC regions, with invitations distributed to eligible practices by email. Purposive sampling of respondents was used in order to capture a variety of perspectives intended to be broadly representative of differences in the demographics of populations served by participating practices and varying levels of experience among participating HCPs, with responses from healthcare assistants, qualified nurses and GPs all being sought. Data collection All interviews were conducted via Zoom between October 2020 and May 2021 by a single author (Author 1, a GP with a particular interest in the epidemiology and management of liver disease in primary care). All interviews were digitally recorded, anonymised and then transcribed verbatim by a professional third party service. A topic guide was developed (supplementary document 1); this was informed by previous research with further input from the multidisciplinary project group, including patient and public involvement (PPI) representatives. To maintain an overall focus while allowing for a degree of flexibility, we used a semi-structured approach informed by normalisation process theory (NPT). By way of explanation, NPT is a middle-range implementation theory that addresses factors needed for successful implementation and integration of interventions into routine work (normalisation). 9,10 It is comprised of four constructs: coherence, cognitive participation, collective action, and reflexive monitoring, which can briefly be defined as follows: coherence - the work that people do to understand and make sense of a practice; cognitive participation - the work that people do to engage and support a new practice; collective action - the work that people do to enact a new practice, to make it workable and to integrate it in context; reflexive monitoring - the work that people do to reflect on and evaluate enacting a new practice in context. As data collection progressed, the topic guide was iteratively modified in response to initial interviews. Interviewing continued until it was judged that no further depth or complexity was being added to the data. Data analysis Collection and analysis of the data were conducted concurrently, with analysis starting as soon as initial interviews had been transcribed. Interview data were coded using N-vivo software (version 12) and then analysed thematically by applying principles of constant comparison. 11 Although NPT had been used to inform the topic guide and to ensure that relevant data were collected, an inductive approach to analysis was employed whereby participants were not constrained solely to NPT categories, thus allowing participants the freedom to raise any issues that were of particular importance to them. All transcriptions were coded by the author who conducted the interviews before being independently analysed by at least two authors, with further discussion amongst authors as required in order to further refine any developing themes. As analysis was ongoing, it became clear that professional boundaries, and the ability to control these boundaries, could help explain many of the implementation challenges that we were analysing in the data. Further analysis and retrospective re-coding of early interviews was therefore carried out, guided by boundary theory as a framework of explanation. Boundary theory explores how professional roles and boundaries between occupations have been ‘constructed’ at an individual and social level by practitioners to maintain occupational control and professional autonomy. 12 These micro level social processes where boundaries are constructed and negotiated are referred to as ‘bounday work’. 13,14 Maintaining these occupational boundaries is felt to require securing a monopoly over exclusive areas of knowledge as well as tasks. 12 As well as these social/micro processes working dynamically to construct and maintain boundaries, there are often external system/policy/macro processes at play. 15 Individual professionals may have little individual control over these processes or ‘system boundaries’. A final set of themes was agreed on by all co-authors. Ethical approval: This study received approval from the health research authority (HRA) (ref 20/HRA/3820). It also received ethical approval from Newcastle University (Ref: 3602/2020). Results Twenty online interviews were carried out with health care professionals (HCP) working in general practice in the North East and North Cumbria region of England. Participants were members of the nursing team (seven) (including nurse practitioners, practice nurses and health care assistants) and GPs (13). Interviews lasted between 30 and 60 minutes. Themes that encapsulate the interviewees’ perceptions and views are reported. They all relate in different ways, to the role of structural boundaries in influencing understanding, worth and roles within chronic disease management. As interview topic guides were developed to examine potential barriers and facilitators to the effective implementation of a chronic liver disease management pathway in primary care, themes were also developed and analysed with regard to the constructs of normalisation process theory. Direct quotations are presented to illustrate common themes whilst also highlighting any outlying views. Definitions of chronic disease work When asked about chronic disease management and how liver disease may or may not ‘fit’, participants employed an external or ‘system’ based understanding of chronic disease, rather than drawing on their medical knowledge. Participants defined and understood chronic disease as those conditions covered by guidelines and protocols, and on the ‘usual’ or ‘standard’ list. The lists were perceived to be external, fixed and handed down to them, rather than decided by them. Medical conditions that required long-term management rather than acute treatment, but did not sit on this defined list, were simply not discussed in the same way as a ‘chronic disease.’ Well, it’s defined by the disease they’ve got. Yeah so it’s a limited number of diseases but not every disease clearly. We don’t have an annual follow up for say osteoporosis but we do it for rheumatoid arthritis, we do for hypertension, diabetes, asthma. The usual stuff (GP13 - GP partner 30 yrs) The majority of participants - both the GPs and the primary care nurses- saw chronic disease management being led and delivered by the nursing team within practices. The ability of the nursing team to lead in these areas seemed to enforce this ‘set list’ definition of what was understood by chronic disease. This understanding fitted with the primary care nursing team role being seen as very protocol and template driven. I think there’s that sort of standard list isn’t there? That kind of hypertension, diabetes, as you said those are commonly seen as chronic disease. I would definitely say other diseases fall within the remits of GP-led disease rather than fitting into those clinics which are nurse-led. So probably a bit of nursing experience, what they are interested in and what they have experience in makes them confident to term that a chronic disease. (GP12 -salaried GP 8 yrs) This externalised understanding of chronic disease work, as lists and standardised processes to be carried out by the nursing team, left little space for consideration of conditions that were not included. Participants acknowledged that liver disease and others may have an ‘identity crisis’; being defined as neither an acute nor chronic condition. Several participants discussed their experiences of other ‘new’ conditions, particularly chronic kidney disease (CKD) making it into this chronic disease paradigm, citing the framing of CKD within cardiovascular and diabetes care as an important shift, in line with findings from a realist review on CKD management implementation in primary care. 16 This framing shift, along with the incentives, templates and protocols that followed, was widely accepted as having moved CKD from a condition perceived as having a similar identity crisis to liver disease ten years ago, into its current position as a managed chronic condition. Liver disease was not yet understood or defined in the same way. The need and worth of chronic disease work As well as defining an understanding of what chronic disease meant to participants, clinical guidelines, in particular the Quality outcomes Framework (QoF), appeared to override much of the individual practitioners’ critical appraisal of any hierarchy of clinical need. Knowledge of liver disease prevalence and burden, and awareness of the common risk factors for liver disease were high amongst participants but this did not translate into clinical action to manage this group. The need, and by extension the worth, of work was externalised, leading to a feeling of powerlessness to intervene or change work priorities according to clinical need. This seemed to hold true even when there was internal disagreement between what the individual clinician saw as being good clinical care, and what was deemed to be needed according to the incentivised frameworks and guidelines. The network has their areas that you have to do and CCG push their areas that you have to do and actually you’re almost spread too thin to try and do them all and you think , ‘Oh gosh, something else that we’ve got to do on top of everything else and sometimes the things that are pushed are good, they’re good for clinical care and other things aren’t necessarily but you have to do them (GP8 - GP Partner 11 yrs) When participants were questioned on why chronic liver disease was not given the same attention as many other chronic diseases and managed in a structured way, the QoF was directly cited by many as the reason that templates and structured management developed. The absence of any QoF targets for liver disease was then a reason for deprioritising. Participants all distanced themselves from this decision making, again implying that they were powerless to influence ‘decision makers higher up’. A minority of participants acknowledged directly the financial implications of the QoF system on influencing clinical priorities. We’ve obviously got the QoF system which means that we’ve got boxes to tick in order to get money so that makes sure that chronic disease are manged because every practice wants to make sure that they get their income and therefore there’s a motivational drive to do that. (GP3 - GP manager, previously GP Partner) This neglect of non-incentivised aspects of care has been noted in other research examining the impact of financial incentives on internal motivation in UK primary care, 17 although the GPs in that study described this neglect as something ‘others were doing’ rather than directly relating this to their own practice. When asked how management of chronic liver disease would change if certain aspects were incentivised, i.e. if liver disease ‘made it’ onto the QoF, there was universal acceptance that it would immediately transform into an area of need and worth. Participants described that their ability to carry out evidence-based reviews would be easier with the centrally commissioned templates, protocols and guidelines that would come with liver disease being added to the QoF. It was felt that the whole team would understand the value and need to carry out these reviews. This need did not relate to participants valuing liver disease as suddenly more clinically important, but rather the need to be guided by the QoF and what it contained. Well clearly we have to achieve various targets for QoF so that does guide us as to what we need to do at each annual review so if liver disease was part of that QoF process that would certainly up the ante because we would have to do it. I think it’s a little bit of an afterthought at the moment so yes if that was incentivised that would definitely put it higher up the agenda (NP2 nurse practitioner -diabetes lead 14 yrs) A minority of participants shared their disquiet over the unintended consequences of financial incentives. Some disagreed with incentive driven care, arguing that the need and worth of work should relate only to improving long term health. When these participants criticized what they saw as the financial motivation of others, comparing it to their reported ‘clinical-need’ based model, it was still based on being ‘instructed’ on what to focus on by others. Participants would need to be ‘told’ to improve work in a clinical area by others who were seen as the decision makers, rather than relying on their own medical knowledge. Even though the worth of the work to these participants came from a different motivation, the driver was still externalised. Sadly, the more that I’ve done general practice I see people over the years who are colleagues at other practices who probably wouldn’t see it as their job unless they were paid to do it. My feeling is that in primary care we look after people and actually if it’s a way of improving health long-term then we should be doing it whether there’s money attached to it or not. I think it is – to me it’s core and there’s various bits and pieces over the years that we have stopped having to do therefore new things should replace it and if liver function or liver disease is the new thing to get on top of, yeah it should be something that if we are told to do we should just get on a do it. (GP4 -GP Partner 18yrs) Incentivisation of liver disease was seen as a crucial step by the majority of participants. Although other research in this area has found that internal motivation to manage established disease was not blocked by the introduction of the QoF, they also found the introduction of new conditions, not already part of routine practice, caused greater concern in diverting attention and challenging clinical autonomy, as with our findings. 17 Defining roles in chronic disease work Participants described defined roles within practices for chronic disease work. Health care assistants (HCA) and nursing teams were established as key practice staff carrying out the routine care. HCAs were perceived to be skilled at information gathering and following templates, whilst nursing staff monitor and interpret results according to clinical guidelines. Outcomes were often defined, with QoF providing target ranges for patient parameters, for example. Lack of complete autonomy in these nursing roles was generally accepted, and as long as there were clear instructions to follow, the nursing team were seen to be an easy ‘fit’ for liver disease management within these established roles. From the healthcare assistants point of view they’re already doing a lot and if you just include this in the lifestyle advice and the blood tests and things that they’re doing and following the template I think that’s absolutely fine, but I think the nursing staff are going to be more key if I’m honest in a lot of this rather than the GPs. It’s not outside of their (nurses) scope of practice, it’s not something that they’re not competent to do. They absolutely are and they are the best people to deliver this, I would say. (GP3 - GP manager, previously GP Partner ) The role of the GP was less clear, more varied and had shifted over time due to the nursing team gradually taking on the management of those conditions well established on the chronic disease ‘list’. This restratification of work within primary health care teams has been studied and interpreted as GPs accepting the need to follow guidelines but not allowing it to constrain the autonomy of their own clinical work. 18 The GP participants reported as a result of this, feeling quite disconnected and powerless in chronic disease work. Some participants discussed a clinical lead role for GPs for specific chronic conditions, e.g. being the named ‘diabetes clinical lead’, but these roles were often felt to have been imposed at the time of the introduction of the QoF, and did not reflect GPs having developed and maintained a specific clinical interest in the area. Do you think the reason that you have designated special interests in things is driven by targets and QoF? Yeah , yep I do . I think I was lead GP for diabetes before QoF was invented a long time ago. Yah but I remember when QoF began we'd split up all the targets into between four or five of us. Yeah, worked out, who would be the lead for each one. That kind of stuck forever. (GP2 -GP Partner 21 yrs) Although GPs were still seen as the ‘leads’ in many areas of chronic disease management they did not see themselves, and were not seen by nursing colleagues as having the ultimate decision-making role in setting the chronic disease management agenda. Participants had varying views of who fulfilled this role and who would need to be involved for chronic liver disease to become part of routine chronic disease work. I guess it’s just not had the priority given to it at a higher level – from the point of view of putting it in to QoF and saying this is a chronic disease that needs to be managed in primary care from um, yeah from decision makers higher up I guess. It’s not been prioritised in the same way. I don’t know really. (GP3 - GP manager, previously GP Partner) A majority of participants claimed that although they were unsure of who exactly was filling this decision making role, they were sure these decisions on what was deemed worthy to manage as a chronic disease in primary care were evidence based. Others were slightly more cynical around the rigour of decision making. It’s a tricky one because there’s such an emphasis on QoF that it can drown out smaller voices and it’s whoever – I presume it’s NICE who decide on the QoF indicators for each year, it’s working out why some things are prioritised over others and the nature of the prioritisation and how – whether or not – it’s almost like which group shouts loudest (HCA2 - health care assistant 3 yrs) Participants suggested that the nursing team had a defined, protocol driven role in existing chronic disease management. The GP role was more varied and less clear, but GPs were perceived not to have complete clinical autonomy in this role which was left to higher level ‘decision makers’. Discussion Summary and main findings The areas that developed as themes within the analysis reflect the macro level drivers perceived to be setting the boundaries of work. The interviewees, despite the open nature of the questioning on chronic disease management in their clinical practice, rarely mentioned any individual factors influencing disease understanding, clinical prioritisation or role in chronic disease management, other than to comment that this individual prioritisation could only come after the core system driven elements were taken care of. These imposed system level boundaries reduced the ability of primary care professionals to set their own individual occupational boundaries and standards. Understanding, roles and responsibilities, and the value of this work were all channelled into an ‘external system’ paradigm. The role of the primary care nursing team has shifted more easily to sit within this protocol/template driven way of working, perhaps due to the fact that any extension to their role into more autonomous decision makers has been fairly recent. Prior to the creation of nurse practitioners and nurse leads in disease areas in primary care, the nursing team saw their role partly as acting on behalf of other decision-making professionals (usually doctors) to fulfil set tasks. As a result, being part of the chronic disease management ‘system’, working to templates and protocols has seemed like a natural extension of this with perceived value and a defined role. For GPs, on the other hand, the loss of autonomy imposed by incentivised standards has led to a ‘dumbing down’ within chronic disease management. In this situation, GPs are seeing themselves as functionaries of other decision-makers (health policymakers at various hierarchical levels). This regression in the ability to form individual and social ‘micro’ level occupational boundaries has led to a feeling of a lack of a role in chronic disease management, and an associated lack of responsibility, or worth, beyond the contractual obligations. Strengths and limitations The robustness of the study was strengthened by use of an action focused implementation theory (NPT) to help develop topic guide and interview structure and boundary theory to inform additional analysis. Participants were aware of the researcher’s professional background which helped build rapport and a common understanding. However, it is acknowledged that this may have influenced the content of participants’ narratives. 19,20 We can’t be certain that participants views were representative of all primary care practice teams, but that was not the intention of the study. The interviews were conducted remotely rather than face to face as initially planned (due to the coronavirus pandemic). This may have influenced rapport and therefore data collected, but improved ease of participation and may have led to more frank discussion than in an more intimidating face to face research environment. Comparison with existing literature Several studies have explored the impact on primary care of a more structured management approach to chronic disease, particularly around the impact of QoF on practice organisation and care delivery. In common with our findings, extensive qualitative work in four GP practices in the UK found that QoF templates seemed to both define the nature of work required, but also act to discourage recording of information not deemed to be important to the ‘process’. 21 Although general practice still promotes a definition of its core values being around patient centred, holistic practice, evidence in the field of chronic disease management related to QoF suggests a different reality. Evidence based medicine leading to centrally defined guidelines and protocols has led to researchers concluding that QoF ‘pays doctors to conform’ in the care of patients with certain defined health conditions, reinforcing a biomedical model of care. 22,18 Our study findings suggest that conforming in care is now so embedded that understanding, worth and roles in these chronic disease areas are ‘set’ with little room for care delivery in conditions that sit outside these structures. This lack of freedom to organise their own work expressed by our study participants has been felt by GPs since the introduction of the early performance targets as far back as the 1990 GP contract. 23 The gradual increase in the relative workload that meeting these targets requires, due to ongoing expansion of target types from an increasingly bureaucratic and multi-layered primary care health structure, (including primary care network (PCN) and integrated care board (ICB) level targets as well national QoF indicators) has only reduced autonomy in this part of clinical work further. Defining roles and responsibilities in chronic disease management, and the impact on professional boundaries has also been widely researched. 24-26 Research analysing the ‘tactics’ general practices used to meet targets, reported the boundary work involved maintaining many of the traditional interprofessional hierarchies within this re-distribution process. 24 They found a move towards ‘upskilling’ at all levels with health care assistants taking on the nursing roles and nurses working more independently in chronic disease work, in line with our findings of well defined roles for the nursing team. What has been described as a role redistribution in chronic disease work, may be viewed through the lens of our findings as more of a substitution, with nowhere obvious to go for the GP within this. These studies had a predominant focus on the micro level social processes involved in boundary construction and assumed an internal focus of control in defining these boundaries, with the GPs involved often citing medical knowledge as ‘setting them apart’ from other occupations. 25,26 Our study found evidence to suggest that for the GPs, this assumed ability to negotiate their role in the context of expanding chronic disease care was being eroded, as the medical knowledge was now defined and handed down by external medical/managerial ‘elites’ (i.e the macro/system boundaries trumped the ability to negotiate the micro). Other studies have reported on this differentiation between groups of physicians into the ‘rank and file’ answering to the ‘medical elites’ and how this has affected GP clinical autonomy. 22,27 Implications for future research/practice This lack of clinical autonomy - defined as an inability of the individual physician to determine their own clinical practices and evaluate their own performances, 22 goes to the core of the definition of professionalism. Sociological literature has traditionally defined professions by traits/characterisitics that distinguish them from other occupations e.g. training, a body of knowledge and codes of ethics. This requires a professional to be able to construct and manage those individual and social boundaries between them and other occupations/team members - the ‘boundary work’ mentioned in the methods. The implications of not having control over this boundary work around chronic disease has implications for professional identity. This may just represent a change in identity to incorporate these different external parameters whilst still maintaining clinical autonomy in other areas of practice as suggested by previous work, 18 but exemplifies a worrying erosion of identity through external systems. The findings should be used to help guide implementation of new pathways of chronic disease care (such as chronic liver disease) in the primary care setting. If, as suggested in this study, the understanding, perceived value and roles of chronic disease work are all determined by system level factors, rather than individual factors, then implementation needs to target those in positions of authority (those who still do have political decision making power within the medical profession). Alternatively the whole system needs to be adapted to allow time and support for conditions that don’t make it onto the national agenda to be adopted as clinical priorities by individuals or practices - giving back that professional autonomy role to the coal face practitioners. With ever increasing numbers of targets in primary care, from every level of the health system structure, it seems the system will continue to hold the trump card. There is more need than ever for health policy makers to be held to account and their decision making scrutinised and questioned. If we fail to do this as a profession, then people with Cinderella conditions such as liver disease will continue to be forgotten. Declarations Acknowlegements: We would like to thank all the participants who agreed to be interviewed for this study. References Harrison, S. and Ahmad, W.I.U. (2000) Medical autonomy and the UK state: 1975 to 2025, Sociology, 34, 1, 129–46. Charles-Jones H, Latimer J, May C. 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Professional legitimacy claims in the multidisciplinary workplace: the case of heart failure care. Sociology of Health & Illness. 2008;30(2):289–308. Norris P. How ‘we’ are different from ‘them’: occupational boundary maintenance in the treatment of musculo-skeletal problems. Sociology of Health & Illness. 2001;23(1):24–43. Friedson E. The reorganization of the medical profession. Med Care Rev. 1985;42(1):11–35. Supplementary Document 1 Supplementary Document 1 is not available with this version Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4183178","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288801368,"identity":"e0866f1b-9b1a-45a6-8ccf-1269f6ac8948","order_by":0,"name":"Helen Jarvis","email":"data:image/png;base64,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","orcid":"","institution":"Newcastle University","correspondingAuthor":true,"prefix":"","firstName":"Helen","middleName":"","lastName":"Jarvis","suffix":""},{"id":288801369,"identity":"24a20412-c083-4b35-81ae-8b422ba2fa30","order_by":1,"name":"Tom Sanders","email":"","orcid":"","institution":"Northumbria University","correspondingAuthor":false,"prefix":"","firstName":"Tom","middleName":"","lastName":"Sanders","suffix":""},{"id":288801370,"identity":"fbbc84db-fb9e-488f-a695-017205106953","order_by":2,"name":"Barbara Hanratty","email":"","orcid":"","institution":"Newcastle University","correspondingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Hanratty","suffix":""}],"badges":[],"createdAt":"2024-03-28 15:14:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4183178/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4183178/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55533489,"identity":"286abcda-e2d8-46dc-8bb3-9674bfb2e93e","added_by":"auto","created_at":"2024-04-29 16:07:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":372259,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4183178/v1/2d41f2c7-d208-4cd5-a414-1729baf68320.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLiver disease as new work in the context of protocolised primary care - Do GPs have a role? A qualitative interview study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe organisation of General Practice has changed rapidly over the last 30 years. At the inception of the National Health Service (NHS) in 1948, general medical practitioners (GPs) retained a unique status amongst medical professionals as self-employed individuals. GPs were contracted and funded to provide services to the NHS, with payments primarily based on registered patient numbers. The imposition of the 1990 GP contract was the start of a gradual and persistent shift towards linking GP remuneration to meeting performance targets. Incentivised targets for providing health promotion/prevention and chronic disease management are now an integral part of modern general practice, with continued expansion at both national and local levels of government health policy. Performance targets in these areas have normalised the use of biomedical research evidence summarised in clinical guidelines and protocols, as a core component of good medical practice. This shift from high relative autonomy in practice towards implementation of evidence-based targets has been described by researchers as a fundamental shift in general practice towards a \u0026lsquo;scientific bureaucratic medicine\u0026rsquo;,\u003csup\u003e1\u003c/sup\u003e with imposed closer linkage to the wider \u0026lsquo;health care state\u0026rsquo;.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs a result of this orientation towards prevention and performance targets, many chronic diseases in UK primary care (particularly the ones incentivised by the Quality Outcomes Framework (QoF) introduced in the General Medical Services (GMS) 2004 contract)\u003csup\u003e3\u003c/sup\u003e are strictly managed in a routine, protocol driven way. This usually consists of an annual chronic disease check, with defined monitoring bloods and observations taken and then interventions enacted, aiming to move any disease parameters within the \u0026lsquo;normal\u0026rsquo; or target ranges.\u003c/p\u003e \u003cp\u003eLiver disease, mainly due to alcohol related liver disease (ARLD) and/or non-alcohol related fatty liver disease (NAFLD) in the UK, is often chronic in the sense that it requires long term management and modification of known risk factors. Despite this, its management in primary care across the UK is variable with only a minority of areas reporting defined pathways of care for people with liver disease.\u003csup\u003e4\u003c/sup\u003e No liver disease outcomes have ever been part of the QoF or any other national incentivised schemes in primary care health policy. Its importance as a leading cause of premature morbidity and mortality has however been increasingly recognised, with earlier detection and management of liver disease cited in national commissions and guidelines as a key priority.\u003csup\u003e5,6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe aim of this study was to explore with primary care professionals the challenges of care for a \u0026lsquo;new\u0026rsquo; disease - chronic liver disease - being implemented in this protocol driven context. We aimed to study the role that targets, guidelines and incentives have played in chronic disease work, and to analyse how these structural boundaries have influenced the ability of primary care to take on new work and maintain professional roles.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eDesign\u003c/p\u003e \u003cp\u003e Thematic analysis of qualitative data obtained through semi-structured interviews with health care professionals (HCP) working in primary care in the North East and North Cumbria (NENC) regions, England. The findings of this study are presented in accordance with the standards for reporting qualitative research.\u003csup\u003e7\u003c/sup\u003e The interviews used for this qualitative analysis have also been used in previous work published by this study team to answer a related but distinct question around the barriers and facilitators to implementing liver disease pathways in primary care. \u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRecruitment\u003c/p\u003e \u003cp\u003eParticipants were recruited from primary care commissioning networks in the NENC regions, with invitations distributed to eligible practices by email. Purposive sampling of respondents was used in order to capture a variety of perspectives intended to be broadly representative of differences in the demographics of populations served by participating practices and varying levels of experience among participating HCPs, with responses from healthcare assistants, qualified nurses and GPs all being sought.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eAll interviews were conducted via Zoom between October 2020 and May 2021 by a single author (Author 1, a GP with a particular interest in the epidemiology and management of liver disease in primary care). All interviews were digitally recorded, anonymised and then transcribed verbatim by a professional third party service. A topic guide was developed (supplementary document 1); this was informed by previous research with further input from the multidisciplinary project group, including patient and public involvement (PPI) representatives. To maintain an overall focus while allowing for a degree of flexibility, we used a semi-structured approach informed by normalisation process theory (NPT).\u003c/p\u003e \u003cp\u003eBy way of explanation, NPT is a middle-range implementation theory that addresses factors needed for successful implementation and integration of interventions into routine work (normalisation).\u003csup\u003e9,10\u003c/sup\u003e It is comprised of four constructs: coherence, cognitive participation, collective action, and reflexive monitoring, which can briefly be defined as follows:\u003c/p\u003e \u003cp\u003ecoherence - the work that people do to understand and make sense of a practice;\u003c/p\u003e \u003cp\u003ecognitive participation - the work that people do to engage and support a new practice;\u003c/p\u003e \u003cp\u003ecollective action - the work that people do to enact a new practice, to make it workable and to integrate it in context;\u003c/p\u003e \u003cp\u003ereflexive monitoring - the work that people do to reflect on and evaluate enacting a new practice in context.\u003c/p\u003e \u003cp\u003eAs data collection progressed, the topic guide was iteratively modified in response to initial interviews. Interviewing continued until it was judged that no further depth or complexity was being added to the data.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eCollection and analysis of the data were conducted concurrently, with analysis starting as soon as initial interviews had been transcribed. Interview data were coded using N-vivo software (version 12) and then analysed thematically by applying principles of constant comparison.\u003csup\u003e11\u003c/sup\u003e Although NPT had been used to inform the topic guide and to ensure that relevant data were collected, an inductive approach to analysis was employed whereby participants were not constrained solely to NPT categories, thus allowing participants the freedom to raise any issues that were of particular importance to them. All transcriptions were coded by the author who conducted the interviews before being independently analysed by at least two authors, with further discussion amongst authors as required in order to further refine any developing themes.\u003c/p\u003e \u003cp\u003eAs analysis was ongoing, it became clear that professional boundaries, and the ability to control these boundaries, could help explain many of the implementation challenges that we were analysing in the data. Further analysis and retrospective re-coding of early interviews was therefore carried out, guided by boundary theory as a framework of explanation. Boundary theory explores how professional roles and boundaries between occupations have been \u0026lsquo;constructed\u0026rsquo; at an individual and social level by practitioners to maintain occupational control and professional autonomy.\u003csup\u003e12\u003c/sup\u003e These micro level social processes where boundaries are constructed and negotiated are referred to as \u0026lsquo;bounday work\u0026rsquo;.\u003csup\u003e13,14\u003c/sup\u003e Maintaining these occupational boundaries is felt to require securing a monopoly over exclusive areas of knowledge as well as tasks.\u003csup\u003e12\u003c/sup\u003e As well as these social/micro processes working dynamically to construct and maintain boundaries, there are often external system/policy/macro processes at play.\u003csup\u003e15\u003c/sup\u003e Individual professionals may have little individual control over these processes or \u0026lsquo;system boundaries\u0026rsquo;.\u003c/p\u003e \u003cp\u003eA final set of themes was agreed on by all co-authors.\u003c/p\u003e \u003c/div\u003e\u003cp\u003eEthical approval: This study received approval from the health research authority (HRA) (ref 20/HRA/3820). It also received ethical approval from Newcastle University (Ref: 3602/2020).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eTwenty online interviews were carried out with health care professionals (HCP) working in general practice in the North East and North Cumbria region of England. Participants were members of the nursing team (seven) (including nurse practitioners, practice nurses and health care assistants) and GPs (13). Interviews lasted between 30 and 60 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThemes that encapsulate the interviewees\u0026rsquo; perceptions and views are reported. They all relate in different ways, to the role of structural boundaries in influencing understanding, worth and roles within chronic disease management. As interview topic guides were developed to examine potential barriers and facilitators to the effective implementation of a chronic liver disease management pathway in primary care, themes were also developed and analysed with regard to \u0026nbsp;the constructs of normalisation process theory.\u003c/p\u003e\n\u003cp\u003eDirect quotations are presented to illustrate common themes whilst also highlighting any outlying views.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinitions of chronic disease work\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked about chronic disease management and how liver disease may or may not \u0026lsquo;fit\u0026rsquo;, participants employed an external or \u0026lsquo;system\u0026rsquo; based understanding of chronic disease, rather than drawing on their medical knowledge. Participants defined and understood chronic disease as those conditions covered by guidelines and protocols, and on the \u0026lsquo;usual\u0026rsquo; or \u0026lsquo;standard\u0026rsquo; list. The lists were perceived to be external, fixed and handed down \u003cem\u003eto\u003c/em\u003e them, rather than decided \u003cem\u003eby\u003c/em\u003e them. \u0026nbsp; Medical conditions that required long-term management rather than acute treatment, but did not sit on this defined list, were simply not discussed in the same way as a \u0026lsquo;chronic disease.\u0026rsquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWell, it\u0026rsquo;s defined by the disease they\u0026rsquo;ve got. Yeah so it\u0026rsquo;s a limited number of diseases but not every disease clearly. We don\u0026rsquo;t have an annual follow up for say osteoporosis but we do it for rheumatoid arthritis, we do for hypertension, diabetes, asthma. The usual stuff (GP13 - GP partner 30 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of participants - both the GPs and the primary care nurses- saw chronic disease management being led and delivered by the nursing team within practices. The ability of the nursing team to lead in these areas seemed to enforce this \u0026lsquo;set list\u0026rsquo; definition of what was understood by chronic disease. This understanding fitted with the primary care nursing team role being seen as very protocol and template driven.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think there\u0026rsquo;s that sort of standard list isn\u0026rsquo;t there? That kind of hypertension, diabetes, as you said those are commonly seen as chronic disease. I would definitely say other diseases fall within the remits of GP-led disease rather than fitting into those clinics which are nurse-led. So probably a bit of nursing experience, what they are interested in and what they have experience in makes them confident to\u003cstrong\u003e\u0026nbsp;term\u0026nbsp;\u003c/strong\u003ethat a chronic disease. (GP12 -salaried GP 8 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis externalised understanding of chronic disease work, as lists and standardised processes to be carried out by the nursing team, left little space for consideration of conditions that were not included. Participants acknowledged that liver disease and others may have an \u0026lsquo;identity crisis\u0026rsquo;; being defined as neither an acute nor chronic condition. Several participants discussed their experiences of other \u0026lsquo;new\u0026rsquo; conditions, particularly chronic kidney disease (CKD) making it into this chronic disease paradigm, citing the framing of CKD within cardiovascular and diabetes care as an important shift, in line with findings from a realist review on CKD management implementation in primary care.\u003csup\u003e16\u003c/sup\u003e This framing shift, along with the incentives, templates and protocols that followed, was widely accepted as having moved CKD from a condition perceived as having a similar identity crisis to liver disease ten years ago, into its current position as a managed chronic condition. Liver disease was not yet understood or defined in the same way.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe need and worth of chronic disease work\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs well as defining an understanding of what chronic disease meant to participants, clinical guidelines, in particular the Quality outcomes Framework (QoF), appeared to override much of the individual practitioners\u0026rsquo; critical appraisal of any hierarchy of clinical need. Knowledge of liver disease prevalence and burden, and awareness of the common risk factors for liver disease were high amongst participants but this did not translate into clinical action to manage this group. The need, and by extension the worth, of work was externalised, leading to a feeling of powerlessness to intervene or change work priorities according to clinical need. This seemed to hold true even when there was internal disagreement between what the individual clinician saw as being good clinical care, and what was deemed to be needed according to the incentivised frameworks and guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe network has their areas that you \u003cstrong\u003ehave\u0026nbsp;\u003c/strong\u003eto do and CCG push their areas that you \u003cstrong\u003ehave\u003c/strong\u003e to do and actually you\u0026rsquo;re almost spread too thin to try and do them all and you think , \u0026lsquo;Oh gosh, something else that we\u0026rsquo;ve got to do on top of everything else and sometimes the things that are pushed are good, they\u0026rsquo;re good for clinical care and \u0026nbsp;other things aren\u0026rsquo;t necessarily but you \u003cstrong\u003ehave\u0026nbsp;\u003c/strong\u003eto do them (GP8 - GP Partner 11 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen participants were questioned on \u003cem\u003ewhy\u0026nbsp;\u003c/em\u003echronic liver disease was not given the same attention as many other chronic diseases and managed in a structured way, the QoF was directly cited by many as the reason that templates and structured management developed. The absence of any QoF targets for liver disease was then a reason for deprioritising. Participants all distanced themselves from this decision making, again implying that they were powerless to influence \u0026lsquo;decision makers higher up\u0026rsquo;. A minority of participants acknowledged directly the financial implications of the QoF system on influencing clinical priorities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe\u0026rsquo;ve obviously got the QoF system which means that we\u0026rsquo;ve got boxes to tick in order to get money so that makes sure that chronic disease are manged because every practice wants to make sure that they get their income and therefore there\u0026rsquo;s a motivational drive to do that.\u003c/em\u003e (GP3 - GP manager, previously GP Partner)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u003c/em\u003eThis neglect of non-incentivised aspects of care has been noted in other research examining the impact of financial incentives on internal motivation in UK primary care,\u003csup\u003e17\u003c/sup\u003e although the GPs in that study described this neglect as something \u0026lsquo;others were doing\u0026rsquo; rather than directly relating this to their own practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen asked how management of chronic liver disease would change if certain aspects were incentivised, i.e. if liver disease \u0026lsquo;made it\u0026rsquo; onto the QoF, there was universal acceptance that it would immediately transform into an area of need and worth. Participants described that their ability to carry out evidence-based reviews would be easier with the centrally commissioned templates, protocols and guidelines that would come with liver disease being added to the QoF. It was felt that the whole team would understand the value and need to carry out these reviews. This need did not relate to participants valuing liver disease as suddenly more clinically important, but rather the need to be guided by the QoF and what it contained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWell clearly \u003cstrong\u003ewe have to\u0026nbsp;\u003c/strong\u003eachieve various targets for QoF so that does guide us as to what we \u003cstrong\u003eneed\u003c/strong\u003e to do at each annual review so if liver disease was part of that QoF process that would certainly up the ante because we would \u003cstrong\u003ehave to\u0026nbsp;\u003c/strong\u003edo it. I think it\u0026rsquo;s a little bit of an afterthought at the moment so yes if that was incentivised that would definitely put it higher up the agenda (NP2 nurse practitioner -diabetes lead 14 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA minority of participants shared their disquiet over the unintended consequences of financial incentives. Some disagreed with incentive driven care, arguing that the need and worth of work should relate only to improving long term health. When these participants criticized what they saw as the financial motivation of others, comparing it to their reported \u0026lsquo;clinical-need\u0026rsquo; based model, \u0026nbsp;it was still based on being \u0026lsquo;instructed\u0026rsquo; on what to focus on by others. Participants would need to be \u0026lsquo;told\u0026rsquo; to improve work in a clinical area by others who were seen as the decision makers, rather than relying on their own medical knowledge. Even though the worth of the work to these participants came from a different motivation, the driver was still externalised.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSadly, the more that I\u0026rsquo;ve done general practice I see people over the years who are colleagues at other practices who probably wouldn\u0026rsquo;t see it as their job unless they were paid to do it. My feeling is that in primary care we look after people and actually if it\u0026rsquo;s a way of improving health long-term then we should be doing it whether there\u0026rsquo;s money attached to it or not. I think it is \u0026ndash; to me it\u0026rsquo;s core and there\u0026rsquo;s various bits and pieces over the years that we have stopped \u003cstrong\u003ehaving\u0026nbsp;\u003c/strong\u003eto do therefore new things should replace it and if liver function or liver disease is the new thing to get on top of, yeah it should be something that if we are \u003cstrong\u003etold\u0026nbsp;\u003c/strong\u003eto do we should just get on a do it. (GP4 -GP Partner 18yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIncentivisation of liver disease was seen as a crucial step by the majority of participants. Although other research in this area has found that internal motivation to manage established disease was not blocked by the introduction of the QoF, they also found the introduction of new conditions, not already part of routine practice, caused greater concern in diverting attention and challenging clinical autonomy, as with our findings.\u003csup\u003e17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefining roles in chronic disease work\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described defined roles within practices for chronic disease work. Health care assistants (HCA) and nursing teams were established as key practice staff carrying out the routine care. HCAs were perceived to be skilled at information gathering and following templates, whilst nursing staff monitor and interpret results according to clinical guidelines. Outcomes were often defined, with QoF providing target ranges for patient parameters, for example. Lack of complete autonomy in these nursing roles was generally accepted, and as long as there were clear instructions to follow, the nursing team were seen to be an easy \u0026lsquo;fit\u0026rsquo; for liver disease management within these established roles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFrom the healthcare assistants point of view they\u0026rsquo;re already doing a lot and if you just include this in the lifestyle advice and the blood tests and things that they\u0026rsquo;re doing and following the template I think that\u0026rsquo;s absolutely fine, but I think the nursing staff are going to be more key if I\u0026rsquo;m honest in a lot of this rather than the GPs. \u0026nbsp;It\u0026rsquo;s not outside of their (nurses) scope of practice, it\u0026rsquo;s not something that they\u0026rsquo;re not competent to do. They absolutely are and they are the best people to deliver this, I would say. (GP3 -\u0026nbsp;\u003c/em\u003eGP manager, previously GP Partner\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe role of the GP was less clear, more varied and had shifted over time due to the nursing team gradually taking on the management of those conditions well established on the chronic disease \u0026lsquo;list\u0026rsquo;. This restratification of work within primary health care teams has been studied and interpreted as GPs accepting the need to follow guidelines but not allowing it to constrain the autonomy of\u003cem\u003e\u0026nbsp;their\u003c/em\u003e own clinical work.\u003csup\u003e18\u003c/sup\u003e The GP participants reported as a result of this, feeling quite disconnected and powerless in chronic disease work. Some participants discussed a clinical lead role for GPs for specific chronic conditions, \u0026nbsp;e.g. being the named \u0026lsquo;diabetes clinical lead\u0026rsquo;, but these roles were often felt to have been imposed at the time of the introduction of the QoF, and did not reflect GPs having developed and maintained a specific clinical interest in the area.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDo you think the \u0026nbsp;reason that you have designated special interests in things is driven by targets and QoF?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYeah , yep I do . I think I was lead GP for diabetes before QoF was invented a long time ago. Yah but I remember when QoF began we\u0026apos;d split up all the targets into between four or five of us. Yeah, worked out, who would be the lead for each one. That kind of stuck forever. (GP2 -GP Partner 21 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough GPs were still seen as the \u0026lsquo;leads\u0026rsquo; in many areas of chronic disease management they did not see themselves, and were not seen by nursing colleagues as having the ultimate decision-making role in setting the chronic disease management agenda. Participants had varying views of who fulfilled this role and who would need to be involved for chronic liver disease to become part of routine chronic disease work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI guess it\u0026rsquo;s just not had the priority given to it \u003cstrong\u003eat a higher level\u0026nbsp;\u003c/strong\u003e\u0026ndash; from the point of view of putting it in to QoF and saying this is a chronic disease that needs to be managed in primary care from um, yeah from \u003cstrong\u003edecision makers higher up\u003c/strong\u003e I guess. It\u0026rsquo;s not been prioritised in the same way. I don\u0026rsquo;t know really. (GP3 - GP manager, previously GP Partner)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA majority of participants claimed that although they were unsure of who exactly was filling this decision making role, they were sure these decisions on what was deemed worthy to manage as a chronic disease in primary care were evidence based. Others were slightly more cynical around the rigour of decision making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s a tricky one because there\u0026rsquo;s such an emphasis on QoF that it can drown out smaller voices and it\u0026rsquo;s whoever \u0026ndash; I presume it\u0026rsquo;s NICE who decide on the QoF indicators for each year, it\u0026rsquo;s working out why some things are prioritised over others and the nature of the prioritisation and how \u0026ndash; whether or not \u0026ndash; it\u0026rsquo;s almost like which group shouts loudest (HCA2 - health care assistant 3 yrs)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants suggested that the nursing team had a defined, protocol driven role in existing chronic disease management. The GP role was more varied and less clear, but GPs were perceived not to have complete clinical autonomy in this role which was left to higher level \u0026lsquo;decision makers\u0026rsquo;.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eSummary and main findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe areas that developed as themes within the analysis reflect the macro level drivers perceived to be setting the boundaries of work. The interviewees, despite the open nature of the questioning on chronic disease management in their clinical practice, rarely mentioned any individual factors influencing disease understanding, clinical prioritisation or role in chronic disease management, other than to comment that this individual prioritisation could only come after the core system driven elements were taken care of. These imposed system level boundaries reduced the ability of primary care professionals to set their own individual occupational boundaries and standards. Understanding, roles and responsibilities, \u0026nbsp;and the value of this work were all channelled into an \u0026lsquo;external system\u0026rsquo; paradigm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe role of the primary care nursing team has shifted more easily to sit within this protocol/template driven way of working, perhaps due to the fact that any extension to their role into more autonomous decision makers has been fairly recent. Prior to the creation of nurse practitioners and nurse leads in disease areas in primary care, the nursing team saw their role partly as acting on behalf of other decision-making professionals (usually doctors) to fulfil set tasks. As a result, being part of the chronic disease management \u0026lsquo;system\u0026rsquo;, working to templates and protocols has seemed like a natural extension of this with perceived value and a defined role.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor GPs, on the other hand, the loss of autonomy imposed by incentivised standards has led to a \u0026lsquo;dumbing down\u0026rsquo; within chronic disease management. \u0026nbsp;In this situation, GPs \u0026nbsp;are seeing themselves as functionaries of other decision-makers (health policymakers at various hierarchical levels). This regression in the ability to form individual and social \u0026lsquo;micro\u0026rsquo; level occupational boundaries has led to a feeling of a lack of a role in chronic disease management, and an associated lack of responsibility, or worth, beyond the contractual obligations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe robustness of the study was strengthened by use of an action focused implementation theory (NPT) to help develop topic guide and interview structure and boundary theory to inform additional analysis. \u0026nbsp; Participants were aware of the researcher\u0026rsquo;s professional background which helped build rapport and a common understanding. \u0026nbsp;However, it is acknowledged that this may have influenced the content of participants\u0026rsquo; narratives.\u003csup\u003e19,20\u003c/sup\u003e We can\u0026rsquo;t be certain that participants views were representative of all primary care practice teams, but that was not the intention of the study. The interviews were conducted remotely rather than face to face as initially planned (due to the coronavirus pandemic). This may have influenced rapport and therefore data collected, but improved ease of participation and may have led to more frank discussion than in an more intimidating face to face research environment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison with existing literature\u003c/strong\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies have explored the impact on primary care of a more structured management approach to chronic disease, particularly around the impact of QoF on practice organisation and care delivery. In common with our findings, \u0026nbsp;extensive qualitative work in four GP practices in the UK found that QoF templates seemed to both define the nature of work required, but also act to discourage recording of information not deemed to be important to the \u0026lsquo;process\u0026rsquo;.\u003csup\u003e21\u003c/sup\u003e Although general practice still promotes a definition of its core values being around patient centred, holistic practice, evidence in the field of chronic disease management related to QoF suggests a different reality. Evidence based medicine leading to centrally defined guidelines and protocols has led to researchers concluding that QoF \u0026lsquo;pays doctors to conform\u0026rsquo; in the care of patients with certain defined health conditions, \u0026nbsp;reinforcing a biomedical model of care.\u003csup\u003e22,18\u003c/sup\u003e Our study findings suggest that conforming in care is now so embedded that understanding, worth and roles in these chronic disease areas are \u0026lsquo;set\u0026rsquo; with little room for care delivery in conditions that sit outside these structures. This lack of freedom to organise their own work expressed by our study participants has been felt by GPs since the introduction of the early performance targets as far back as the 1990 GP contract.\u003csup\u003e23\u003c/sup\u003e The gradual increase in the relative workload that meeting these targets requires, due to ongoing expansion of target types from an increasingly bureaucratic and multi-layered primary care health structure, (including primary care network (PCN) and integrated care board (ICB) level targets as well national QoF indicators) has only reduced autonomy in this part of clinical work further.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDefining roles and responsibilities in chronic disease management, and the impact on professional boundaries has also been widely researched.\u003csup\u003e24-26\u003c/sup\u003e Research analysing the \u0026lsquo;tactics\u0026rsquo; general practices used to meet targets, reported the boundary work involved maintaining many of the traditional interprofessional hierarchies within this re-distribution process.\u003csup\u003e24\u003c/sup\u003e\u0026nbsp; They found a move towards \u0026lsquo;upskilling\u0026rsquo; at all levels with health care assistants taking on the nursing roles and nurses working more independently in chronic disease work, in line with our findings of well defined roles for the nursing team. What has been described as a role redistribution in chronic disease work, may be viewed through the lens of our findings as more of a substitution, with nowhere obvious to go for the GP within this. These studies had a predominant focus on the micro level social processes involved in boundary construction and assumed an internal focus of control in defining these boundaries, with the GPs involved often citing medical knowledge as \u0026lsquo;setting them apart\u0026rsquo; from other occupations.\u003csup\u003e25,26\u003c/sup\u003e\u0026nbsp; Our study found evidence to suggest that for the GPs, this assumed ability to negotiate their role in the context of expanding chronic disease care was being eroded, as the medical knowledge was now defined and handed down by external medical/managerial \u0026lsquo;elites\u0026rsquo; (i.e the macro/system boundaries trumped the ability to negotiate the micro). \u0026nbsp;Other studies have reported on this differentiation between groups of physicians into the \u0026lsquo;rank and file\u0026rsquo; answering to the \u0026lsquo;medical elites\u0026rsquo; and how this has affected GP clinical autonomy.\u003csup\u003e22,27\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for future research/practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis lack of clinical autonomy - defined as an inability of the individual physician to determine their own clinical practices and evaluate their own performances, \u003csup\u003e22\u003c/sup\u003e\u0026nbsp; \u0026nbsp;goes to the core of the definition of professionalism. Sociological literature has traditionally defined professions by traits/characterisitics that distinguish them from other occupations e.g. training, a body of knowledge and codes of ethics. This requires a professional to be able to construct and manage those individual and social boundaries between them and other occupations/team members - the \u0026lsquo;boundary work\u0026rsquo; mentioned in the methods. The implications of not having control over this boundary work around chronic disease has implications for professional identity. This may just represent a \u003cem\u003echange\u0026nbsp;\u003c/em\u003ein identity to incorporate these different external parameters whilst still maintaining clinical autonomy in other areas of practice as suggested by previous work,\u003csup\u003e18\u003c/sup\u003e but exemplifies a worrying erosion of identity through external systems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings should be used to help guide implementation of new pathways of chronic disease care (such as chronic liver disease) in the primary care setting. If, as suggested in this study, the understanding, perceived value and roles of chronic disease work are all determined by system level factors, rather than individual factors, then implementation needs to target those in positions of authority (those who still do have political decision making power within the medical profession). Alternatively the whole system needs to be adapted to allow time and support for conditions that don\u0026rsquo;t make it onto the national agenda to be adopted as clinical priorities by individuals or practices - giving back that professional autonomy role to the coal face practitioners. With ever increasing numbers of targets in primary care, from every level of the health system structure, it seems the system will continue to hold the trump card. There is more need than ever for health policy makers to be held to account and their decision making scrutinised and questioned. If we fail to do this as a profession, then people with Cinderella conditions such as liver disease will continue to be forgotten.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowlegements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWe would like to thank all the participants who agreed to be interviewed for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHarrison, S. and Ahmad, W.I.U. (2000) Medical autonomy and the UK state: 1975 to 2025, Sociology, 34, 1, 129\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eCharles-Jones H, Latimer J, May C. Transforming general practice: the redistribution of medical work in primary care. Sociol Health Illn. 2003 Jan;25(1):71\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003ehttps://www.legislation.gov.uk/uksi/2004/291/contents/made\u003c/li\u003e\n\u003cli\u003eJarvis H, Worsfold J, Hebditch V, et al. Engagement with community liver disease management across the UK: a cross-sectional survey. BJGP Open. 2021 Oct;5(5):BJGPO.2021.0085.\u003c/li\u003e\n\u003cli\u003eWilliams R, Alexander G, Aspinall R, et al. Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK. Lancet. 2018 Dec 1;392(10162):2398\u0026ndash;412.\u003c/li\u003e\n\u003cli\u003eMcPherson S, Armstrong MJ, Cobbold JF, et al. Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group. Lancet Gastroenterol Hepatol. 2022 Aug;7(8):755\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eJarvis H, Sanders T, Hanratty B. Liver disease management as routine work in primary care: a qualitative interview study to guide implementation. Br J Gen Pract. 2022 Dec;72(725):e916\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eMay C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology 2009;43:535\u0026ndash;54.\u003c/li\u003e\n\u003cli\u003eMay CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:29.\u003c/li\u003e\n\u003cli\u003eGlaser BG, Strauss AL. \u003cem\u003eDiscovery of grounded theory: strategies for qualitative research.\u003c/em\u003e New York, NY: Routlege; 2017\u003c/li\u003e\n\u003cli\u003eAbbott A. The System of Professions: An Essay on the Division of Expert Labor . Chicago, IL: University of Chicago Press; 1988. 452 p.\u003c/li\u003e\n\u003cli\u003eAbbott A. Boundaries of Social Work or Social Work of Boundaries?: The Social Service Review Lecture. Social Service Review. 1995 Dec;69(4):545\u0026ndash;62. 1.\u003c/li\u003e\n\u003cli\u003eLiu S. Boundary Work and Exchange: The Formation of a Professional Service Market. Symbolic Interaction. 2015;38(1):1\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eFreidson E 1983 The reorganization of the professions by regulation. Law and Human Behavior 7: 279\u0026ndash;290.\u003c/li\u003e\n\u003cli\u003eTsang JY, Blakeman T, Hegarty J, et al. Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review. Implement Sci. 2016 Apr 4;11:47.\u003c/li\u003e\n\u003cli\u003eMcDonald R, Harrison S, Checkland K, et al. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ. 2007 Jun 30;334(7608):1357.\u003c/li\u003e\n\u003cli\u003eHarrison S, Dowswell G. Autonomy and bureaucratic accountability in primary care: what English general practitioners say. Sociology of Health \u0026amp; Illness. 2002;24(2):208\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eChew-Graham CA, May CR, Perry MS. Qualitative research and the problem of judgement: lessons from interviewing fellow professionals. Fam Pract. 2002;19(3):285\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eRichards H, Emslie C. The \u0026lsquo;doctor\u0026rsquo; or the \u0026lsquo;girl from the University\u0026rsquo;? Considering the influence of professional roles on qualitative interviewing. Fam Pract. 2000;17(1):71\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eHuby G, Guthrie B, Grant S, et al. Whither British general practice after the 2004 GMS contract? Stories and realities of change in four UK general practices.Journal of Health Organization and Management. 2008 Jan 1; 22(1):63\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eCheckland K, Harrison S. The impact of the QOF on practice organisation and service delivery. In: The Quality and Outcomes Framework. CRC Press; 2011.\u003c/li\u003e\n\u003cli\u003eCalnan M, Williams S. Challenges to Professional Autonomy in the United Kingdom? The Perceptions of General Practitioners. Int J Health Serv. 1995 Apr 1; 25(2):219\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eGrant S, Huby G, Watkins F, et al. The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study. Sociol Health Illn. 2009 Mar;31(2):229\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eSanders T, Harrison S. Professional legitimacy claims in the multidisciplinary workplace: the case of heart failure care. Sociology of Health \u0026amp; Illness. 2008;30(2):289\u0026ndash;308.\u003c/li\u003e\n\u003cli\u003eNorris P. How \u0026lsquo;we\u0026rsquo; are different from \u0026lsquo;them\u0026rsquo;: occupational boundary maintenance in the treatment of musculo-skeletal problems. Sociology of Health \u0026amp; Illness. 2001;23(1):24\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eFriedson E. The reorganization of the medical profession. Med Care Rev. 1985;42(1):11\u0026ndash;35.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplementary Document 1","content":"\u003cp\u003eSupplementary Document 1 is not available with this version\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4183178/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4183178/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eLiver disease is common, but not part of routine chronic disease management in primary care. The aim of this study was to explore the challenges of implementing pathways of care for liver disease within existing highly protocolised structures in primary care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSemi-structured interviews with 20 health professionals working in primary care. Interviews were informed by normalisation process theory (NPT) and boundary theory. Data were subject to thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree themes were identified relating to chronic disease work; definitions; need and worth, and roles. Participants identified that understanding and value of roles within chronic disease management were pre-defined by targets imposed on them as part of national incentives schemes. Structural boundaries constrained professional autonomy and the potential to influence this area of primary care management, including taking on new work.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThe inability to influence care decisions blurs occupational boundaries and goes to the core of what it means to be a professional. Unless liver disease sits within this target-based system, it is unlikely to become part of routine work in primary care.\u003c/p\u003e","manuscriptTitle":"Liver disease as new work in the context of protocolised primary care - Do GPs have a role? A qualitative interview study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 18:26:59","doi":"10.21203/rs.3.rs-4183178/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3edbb5c5-e8cf-489f-aafe-ac995321b068","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-29T14:06:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-09 18:26:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4183178","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4183178","identity":"rs-4183178","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}