Table 4 Detailed account of themes from qualitative analysis. Provides a more detailed description of the qualitative data as summarised in Table 3
Sense making | Theme | Subtheme | Descriptions from participants |
ITP valued by health care professional | Defines professional role | “our job starts where the guideline ends” (GP) And not just in managing medicines (Nurse Prescriber) | |
ITP valuable to NHS | False economy not to | “could improve care and save money” (GP) “Needs to be developed” (Pharmacist) | |
But uncertain | “so long as patient don’t miss out” (GP) | ||
Clarity on ITP | Prioritising the patient | “advising on the suitability for the patient” (Pharmacist) Principle of personalised medicine | |
Value of ITP not shared | By patients | “pts… need to understand prescribing as important as prescribing” (Pharmacist) | |
By organisational values | “recognition from the powers that be that this is a good thing to do” (GP) | ||
By organisational structures | “would be difficult to instigate in practice due to protocol driven practice” (Nurse Prescriber) “needs recognition that this is clever subtle stuff that needs skilled practitioners…not readily done by rote” (GP) | ||
Engagement | Theme | Subtheme | Descriptions |
Leadership | Individuals | Key leaders, influential colleagues, trained colleagues support engagement. “working through examples with trusted colleagues” (pharmacist) “I remember a Protected Learning Time session where a geriatrician talked about the rationale for stopping nearly all the medication” (GP) Independent contractual status for GPs supports engagement | |
Collective action | Multidisciplinary team working enhances engagement with ITP | ||
Levels of engagement | Variable | Engage with idea if not the practice (GP) Pharmacists role to recognise the potential need even if don’t do ourselves | |
Desire for more | “want to do more discontinuation of meds” (Nurse Prescriber) | ||
Patient engagement | Media | Media input in to dangers and harms of medicines can help as it starts a conversation | |
Barriers to engagements | Excess workload | “limited by time, caseload and so lack of mental capacity” (GP). Time and complexity mitigate against depth of conversation needed. Stopping meds increases workload – follow up consults | |
Fragmentation of care; lack of integration of vision and process | Inefficiency crowding out effort; disparity between primary and secondary perspectives, power and resources; population over individual focus | ||
Fear | Limits engagement “it’s a fear of making a mistake and the potential consequences” (GP) | ||
Patient resistance | Patients can be reluctant to change “can be difficult to persuade carers and patients to change meds they’ve been taking for a long time and were told were for life” (Pharmacist) Patient expectations and lack of understanding of greyness of medicines | ||
Action | Theme | Subthemes | Descriptions |
Formal training | GP training | Generalist training; basic principles; knowing the guidelines before you deviate off “this wasn’t taught when I was training” (GP) | |
Specialist training | Prescribing (stop-start); working within specialist area easier to do ITC | ||
Experiential learning–phronesis | Self taught/experience | “experience gained intuition”; (GP) practiced at doing this over a long time | |
Learn from patients | “just day-to-day learning from patients” (GP) | ||
Learn from colleagues | Trusted colleagues and influential figures; shared reflection including on line discussion | ||
Collective action | Peer discussion | MDT and collaborative action supports ITP (but can inhibit decision making too as need full agreement). Supervision | |
Other support | Media | To start the conversation | |
Partial action | Easier when stopping meds than starting | ||
Barriers | Organisational practice – pay for performance | Lack of joined up thinking and communication; monitoring as a barrier | |
Time | |||
Resource | Qualified and experience staff lacking; resource prioritises opposite approach; imbalance need and supply; peer senior support and continuity of same needed; legal support “resource restriction means prioritise safety and supply” (Pharmacist) | ||
Mental capacity and complexity | “Limited by time caseload and so lack of mental capacity” (GP); exhaustion “To operate outside ‘recognised prescribing’ requires understanding of the clinical evidence supporting the current guidelines, when there are gaps in that evidence and when it is therefore appropriate to choose a different path. An important variable is the patient wishes and how these should be accommodated” (Pharmacist) | ||
Practical advice | Practical advice, a framework, training | ||
Fear | Making and recording defendable decisions; being castigated by others – clinicians, legally, morally; uncertainty re risk “Shared balanced discussions with patients rarely results in a DEFENDABLE decision. If you are way of the mark with clinical decisions then it is probably sensible to share your decision with colleagues” (GP) “Fear of being misunderstood & misinterpreted as undertreatment, apathy, fear of going against guidelines & being medicolegally vulnerable” (GP) | ||
Monitoring | Theme | Subtheme | Discussion |
Mixed feedback | Positive | From patients and colleagues helps confidence, helps staff to prescribe less not more – more PCC “each time I see a positive effect am motivated to do more” (Nurse Prescriber) | |
Negative | From colleagues (secondary care) and patients (complaints) “I stopped metformin in a 90-year-old with dementia, daughter complained, made me wary to deprescribe” (GP) | ||
Challenge of feeding back | Demonstrating impact | Hard to quantify benefits (GP) | |
Challenging the status quo | Fear of feedback | “If there is a problem may be hard if against the guideline” (GP) | |
Monitoring as a barrier | Accept only small deviation, monitoring from population not individual perspective, pressure to prescribe to QOF. “should be a KPI” [KPI = Key Performance indicator] | ||
Potential power of feedback | Should be a KPI |