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

Background Personal continuity -having a GP who knows and follows the patient- is a core value of general practice, yet changes in society and healthcare have challenged its provision. Therefore, we developed TOOL-kit, a multi-component intervention aimed to optimise personal continuity for patients aged 65 or above. Aim to evaluate TOOL-kit's implementation and identify barriers and facilitators influencing its delivery. Design and setting Mixed-methods study embedded in the main effect trial (August 2020 - April 2022). Method Implementation was assessed via 3-monthly surveys, 93 interviews with GPs and practice staff (n=221) from 32 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 socio-political levels. Results Of 32 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 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. Conclusion 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. Keywords General Practice, Continuity of care, Implementation Science, Physician-Patient Relations.