Patients' views on primary care multidisciplinary teams in Scotland: a mixed-methods evaluation

Summary

Four years since the introduction of the new GP contract in Scotland, MDT care has expanded with limited patient awareness, but patients do recognise its potential value. Patients who had received MDT care reported positive experiences and highlighted improved access and added expertise as perceived benefits. However, many patients were unhappy with reception signposting to first-contact MDT care, especially those in deprived urban areas living with multimorbidity. Access to GP care, especially when patients feel they need it for serious or worrying issues, was an overriding priority for many patients, and MDT care was seen as a supplement rather than a substitute for this. Concerns about reception signposting were more likely in those patients who were also concerned about GP access.

There were also differences in patients’ awareness of MDT roles across geographic and socioeconomic groups, as well as by age and multimorbidity. Pharmacy and physiotherapy roles were most familiar to patients with multimorbidity and those in remote and rural areas, while awareness of mental health nurses and link workers was lowest in affluent urban areas. Patients aged ≥65 years had significantly lower awareness of link workers (P = 0.007).

Strengths and limitations

The strengths of this study include its use of mixed methodology to explore and evaluate patient views, the relatively large survey sample, and the inclusion of three populations of interest. The strength of the survey findings are limited by the low response rate of 17% (12% deprived urban versus 27% affluent urban versus 20% remote and rural), although this is not dissimilar to that seen in Scottish Government patient surveys.³¹ Of note, the deprived urban group, which, like in other surveys, had a much lower response rate, was the biggest group in our sample, comprising 58% of distributed surveys. The response rates may also have been limited by the use of a postal survey, rather than in-person data collection at the GP practice, a method that was dictated by the pandemic. Additionally, the funding constraints of the study meant that postal reminders were not possible.

Survey responders differed from non-responders in terms of age in all groups (deprived urban, affluent urban, and remote and rural). In the deprived urban group, responders were also significantly less deprived than non-responders (Supplementary Table S1). While this affects the generalisability of the survey findings, it may in fact mean that the differences found between the deprived urban and affluent urban groups are an underestimate, as those responding were the 'least deprived of the deprived'.

With respect to the qualitative methods, the reliance on telephone rather than face-to-face interviews as a result of the pandemic may have affected the quality of evidence obtained, given the absence of non-verbal communication, although research suggests there is little difference in quality between these modes of interview.³² The recruitment of interviewees from a volunteer subset of questionnaire responders creates a risk of bias since this method may give prominence to those with strong views. However, while our findings do not claim to be fully generalisable, the number of interviews conducted, the purposive sampling method, and the saturation of data suggest that our findings give a valuable representation of the range of views held by patients across geographic and socioeconomic groups and, in particular, older patients with multimorbidity.

The study would be strengthened by the inclusion of data on practice-level differences in MDT care availability, reception signposting methods, and appointment booking systems, as these differences are likely to have influenced patients’ responses. Local variations in the implementation of the contract have been reported, including the provision of MDT services in some areas through ‘hubs’ rather than individual GP practices.^19,33 However, it was not possible to collect data on these practice-level differences within the resource constraints of the study. The high level of awareness of nurse appointments is also likely to have been skewed by the broad definition of ‘nurses’ used in the survey (which covered practice nurses, advanced nurse practitioners, and the support role of healthcare assistants, who are not registered nurses), limiting the interpretation of this finding.

Comparison with existing literature

The differences found in MDT awareness between deprived urban, affluent urban, and remote and rural areas likely reflects differing exposure to MDT care owing to differences in individuals’ health needs and in practices’ MDT provision. Lower MDT awareness in affluent urban areas, for example, is in keeping with the lower frequency of GP attendance, better general health, and lower levels of multimorbidity in these areas, than deprived urban and remote and rural areas.^21,25,34,35 However, significantly higher awareness of mental health nurses was found in remote and rural than affluent urban areas, despite the fact that mental–physical multimorbidity and levels of anxiety and depression are similar between affluent urban and remote and rural areas.²¹ The reasons for this discrepancy are not clear.

A range of challenges affecting the expansion and integration of primary care MDTs in Scotland was highlighted in our recent qualitative evaluations of the views of primary care professionals and stakeholders.^19,20 The importance of involving and engaging patients in the redesign of primary care services has been highlighted by the Organisation for Economic Cooperation and Development (OECD), but our recent systematic scoping review of OECD countries and China found limited evidence of it happening.^13,36

Both the levels of awareness of MDT roles and the acceptability of reception signposting found in this study are very similar to those found in a recent Scottish Government survey with a nationally representative sample of >1000 patients.³⁷ This also showed that patients view the GP as the first point of contact and prefer signposting by a GP, results that echo the findings of our qualitative interviews. Additionally, the Scottish Government survey found high levels of trust in the advice of nurses, physiotherapists, and pharmacists in primary care (76%, 66%, and 65%, respectively, compared with 75% with complete trust in GPs and 52% in mental health nurses).³⁷ These results fit with our interview findings of positive experiences of care for these three MDT roles in particular.

A number of international reviews have highlighted the paucity of evidence evaluating patients’ views and experiences of MDT care.^8,13,22 However, our findings of broadly positive patient experiences are consistent with a recent integrative review of 48 international studies.²³ Interestingly, and in close alignment with our study, as well as finding generally positive patient experiences of MDT care, this review highlighted concerns that increased access to MDT care did not necessarily increase care quality, and that MDT care was 'inconsistently holistic'.²³

Evidence on patients’ views regarding reception signposting is also lacking, although a recent study of staff views reported concerns over the lack of clarity over receptionists’ role and remit, and the need for appropriate training and development.³⁸ These findings echo the reservations expressed by patients in our study. While this paper focuses on the views of patients with respect to MDT expansion, we have also published a more comprehensive summary of patients’ views and experiences of primary care in Scotland.

Implications for research and practice

MDT expansion is a core feature of not only the Scottish GP contract, but also of primary care reforms in healthcare systems elsewhere globally,¹³ and the views and experiences of patients with respect to this are under-explored.^8,13,22 Consequently, this study provides an important insight for all primary care systems undergoing similar changes.

The implementation of the new GP contract in Scotland has clearly been affected by the pandemic, and other challenges to MDT expansion have been identified,^19,20 but further work is needed to assess variations in the availability of primary care MDT services across Scotland, as this has implications for interpreting differences in patient views on these reforms. Our findings, however, suggest that, despite limited awareness of MDT expansion, it has qualified acceptance and generally leads to positive patient experiences.

However, access to GP care remains an overriding priority for patients and MDT care is seen as a supplement rather than a substitute for this. Concerns about reception signposting to first-contact MDT care are especially strong in patients from deprived areas with multimorbidity. These findings represent a barrier to the expansion of first-contact MDT care, and therefore to the new GP contract’s aim of reducing GP workload and freeing-up time for GPs to spend with the most complex patients. Recent research, including our qualitative studies with professionals, suggest this is not yet happening.^19,20,39 Given that this is a key mechanism by which the contract seeks to reduce health inequalities, these issues must be addressed if continued MDT expansion is to benefit those with the most complex needs.