Patient view of the advanced practitioner (AP) role in primary care: A realist‐informed synthesis

Correspondence Leah Morris, Centre for Health and Clinical Research, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK. Email: Leah.morris@uwe.ac.uk Abstract Background: Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative. Aims: This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. Materials & Methods: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory‐specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders. Results: Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas. Discussion: Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change. Conclusion: Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.


| INTRODUCTION
Face-to-face primary care consultations grew by more than 15% between 2010/2011 and 2014/2015, partly due to the ageing population (Majeed, 2014;The King's Fund, 2016). Alongside this, employment of full-time equivalent general practitioners (GPs) has decreased (NHS Digital, 2018). There have been efforts to increase the number of advanced practitioners (APs), partly to fill shortfalls, but also to allow patients early access to specialists (NHS England, 2016). APs are healthcare professionals (HCPs) working at a higher level than initial registration and they should work in, lead and manage a multidisciplinary team; critically address their learning needs; and engage in research (Health Education England [HEE], 2017). Examples of APs include first contact physiotherapists (FCPs), clinical pharmacists, primary care practitioners and the more well-established nurse practitioner (NP) role (HEE and NHS England, 2018;NHS England, 2016).
Ascertaining the patient perspective is vital; if an intervention is considered acceptable, patient adherence to treatment and improved clinical outcomes are more likely (Hommel et al., 2013).
Patient satisfaction is defined around patient beliefs and expectations being met, whereas acceptability is a multifaceted construct (Sekhon et al., 2017). This realist synthesis will explore patient 'views', encapsulating multiple measurements of the patient perspective.

| Aim
Explore the literature on patient views of the AP role in primary care to determine the factors that influence acceptability.

| Objectives
(1) Identify literature relevant to patient acceptability of the AP role.
(3) Establish hypotheses on what makes the AP role acceptable/ unacceptable to patients.
(4) Establish the underlying contexts, mechanisms and outcomes of these hypotheses.

| METHODS
Realist synthesis was adopted, a method which follows the ontology and epistemology of empirical realism and can be undertaken prior to a realist evaluation. Realism is concerned with 'what works for whom, how and under what circumstances' (Pawson et al., 2005, p. 32).
Realist syntheses are suited to complex interventions, such as health care (Rycroft-Malone et al., 2012).
Realists make causal links between the 'context', 'mechanism' and 'outcome', known collectively as 'context-mechanism-outcome (CMO)' configuration'. A programme (the AP) operates within a context which 'triggers' the mechanism that creates an outcome (Wong et al., 2016). In realist syntheses, CMOs are identified from relevant literature and then analysed to form programme theories whilst ensuring stakeholder involvement throughout (Pawson et al., 2005).

| DEFINING THE SCOPE
A broad search of sources formed initial ideas on how the AP role works; these shaped the theory areas (TAs) that acted as the framework for the development of hypotheses (Rycroft-Malone et al., 2012). Two FCPs, a research associate (involved in FCP research) and a patient research partner (referred to collectively as the 'team') met with the researcher (LM) to discuss the TAs, alter as needed or create new TAs.
Seven initial TAs were agreed which formed the TA framework:

| SEARCHING AND APPRAISING THE LITERATURE
An overview of the process for searching and appraising the literature is outlined in Figure 1.
A realist synthesis utilises purposive searching of proposed theories and iterative searches, as programme understanding grows (Pawson et al., 2005) (Pawson et al., 2005). Seven different search strategies were adopted, with terms specific to each theory area and its hypotheses.
Sources were not assessed based on the study design or quality; therefore, grey literature was included (Rycroft-Malone et al., 2012) (see Table 1 for inclusion/exclusion criteria).
The search terms, database, number of hits (titles) and duplicates removed by the database were recorded.

| DATA EXTRACTION AND APPRAISAL
The data extraction sheets (n = 7) collated information on each TA, with questions regarding CMOs, and were piloted by two researchers They were formed from the accumulative picture of CMOs subsequent to data extraction of all studies. To form theory, available evidence, hunches, common-sense and team discussions were utilised (The RAMESES II Project, 2017). An example data extraction sheet is provided in Appendix 1.

| RESULTS
Seven theories were identified from the scoping review, expanded upon and redefined through a systematic review of each TA, resulting in 19 hypotheses related to the patient acceptability of the AP role. 2274 articles were read at title/abstract level and 65 at full-text level, including 14 from snowballing. Thirty-seven articles were included in the review; 5 regarding the physiotherapy FCP role, and 32 studies were nursing roles, Health Visitors, Physician Assistants or Pharmacist Independent Prescribers. A new TA 'professional hierarchy' emerged at the data extraction phase through reading the literature related to the other seven TAs (see Figure 2). The narrative for the hypotheses (Hs) is presented under the relevant context and Table 2 provides further CMO evidence.

| EXPERIENCE OF PREVIOUS GP CONSULTATIONS/APS
Patients formed expectations of AP consultation outcomes through comparison with GP outcomes (Baldwin et al., 1996;Gerard et al., 2014;Wasylkiw et al., 2009) (Hs1-3). Patients were more comfortable with a 'friendly' AP than with a GP (Barratt, 2016; T A B L E 1 Inclusion/exclusion criteria Inclusion: � 'Good and relevant enough' to theory.
� Any profession practising in an advanced role in primary care.

Exclusion:
� Not in a primary care setting.
� Secondary views on behalf of a patient.
� Does not contribute to any programme theories.
� Sources were not research based.
� The AP was not first contact.

| PATIENTS WANT TO UNDERSTAND CLINICIANS' CLINICAL-REASONING/MAKE DECISIONS IN THEIR CARE
Patients wanted the AP to display their knowledge via a thorough assessment and clearly explained information (CSP, 2016;Dhalivaal, 2007;Redsell et al., 2007) (H9). This was associated with the ability for patients to make decisions regarding their care (Edwall & Danielson, 2008). Studies highlighted a patient desire for shared decision-making (Barratt, 2016;Mahomed et al., 2012;Young et al., 2016) (H8).

| PATIENT PERCEIVES THEY HAVE A 'SERIOUS' CONDITION
Although patients were satisfied with-and often expected-APs to prescribe medications (Barratt, 2016;Bergman et al., 2013;Redsell et al., 2007), the expectation remained that they would discuss the prescription with a GP to reduce risk (Bergman et al., 2013) (H13).
Patients wanted to retain the choice of GP access, feeling that GPs had more in-depth knowledge and should diagnose what were considered 'serious incidents' (Halcomb et al., 2013). Serious incidents were predominantly related to the existing conditions (Maul et al., 2015) while patients would consult APs for common colds and infections (Barratt et al., 2016;Myers et al., 1997). Holdsworth and Webster (2004) found that self-referred patients were more likely to have had their condition for a shorter duration (H14).

| PATIENTS SHARING THEIR HEALTHCARE EXPERIENCES WITH OTHERS
Studies explicitly stating the methods for promoting the role to patients were limited and were authors' postulations (Barratt, 2016;Maul et al., 2015). It was highlighted by patients that word of mouth may be an effective means to promote the role (Baldwin et al., 1996) (H18).

| THE ROLE OF GP STAFF IN SIGNPOSTING
Although there was a lack of formal strategy for promoting the role, findings demonstrated that members of the practice team, particularly receptionists, may play a significant part (H19) (Chapple et al., 2000;Cook et al., 2014;Desborough et al., 2016;Fortin et al., 2010;Webster et al., 2008). H19's supporting studies were based upon staff responses and the author's postulations, and not patient views. Analysis suggests that introducing a self-referral role without public education could cause an influx of referrals and increased demand (Webster et al., 2008;Williams & Jones, 2006).

| HIERARCHY WITHIN THE PROFESSIONS
When patients considered the AP to have a high level of knowledge, they occasionally mistook them for a doctor (Chapple et al., 2000) or they undermined the AP's knowledge (Barratt, 2016). Redsell et al. (2006) concluded that patients had internalised traditional roles in primary care due to the existing hierarchical boundaries between professions (see Table 2, Novel 1). Response M: Patient expected confirmation of their belief of a serious condition due to preconceived ideas from GP consultations.

T A B L E 2 Context-mechanism-outcomes
Unintended O: Patient dissatisfied with AP as their expectation was not confirmed. (Barratt, 2016;Caldow et al., 2006;Halcomb et al., 2013;Luker et al., 1998;Mahomed et al., 2012;Maul et al., 2015;Myers et al., 1997;Parker et al., 2012;The EROS Project Team, 1999;Young et al., 2016) Experience 3. Patient perceptions of GPs formed from previous GP consultations will influence the patient acceptability of the AP role. Communication 4. The AP role is more acceptable to patients when the AP has an informal discussion with the patient.
Resource M: AP friendly and consultation more conversational than GP.
Resource M: AP consultation longer than GP consultation. AP answered all patient's questions.
Resource M: Due to practitioner continuity, the AP knew the patient's name/history. Response M: Patient expectation to build a longterm relationship with the AP which they were unable to do with GP.
9. The AP role is more acceptable to patients when the AP demonstrates a high-level of knowledge.
Patients want to understand clinicians' clinical reasoning Resource M: AP thorough in their assessment and information provision. Response M: Patient perceived AP as knowledgeable.
Unintended O: Patients less likely to access AP for prescriptions.
Scope of practice 11. Role more acceptable if AP offers a service that is equivalent to the GP consultation.
Resource M: AP able to carry out medical investigations.

Unintended response M: Uncomfortable with
AP's scope.
Unintended O: Less likely to access an AP if requiring a skill that is an extension of their scope.
Inactive O: Increased enablement of patient to manage their own condition when accessing an AP with a greater scope of practice. (Parker et al., 2012;Gerard et al., 2014;Desborough et al., 2016;Wasylkiw et al., 2009;Baldwin et al., 1996) Experience 12. Previous experience of a prescribing AP increases patient acceptability of a prescribing AP in primary care.
Resource M: AP able to prescribe. Response M: Patients more accepting of AP prescribing due to previous experience.
O: Increased acceptability if reduced waiting times for AP. Patients seen earlier and reassured. 'Freeing up' GP appointments.
16. Patients find the role more acceptable if they expect that an engagement with FCP will provide indirect access to other services.
Resource M: Follow-up appointment with AP. (Luker et al., 1998;Fortin et al., 2010) Unintended response M: Expected AP to be first appointment only, and GP follow-up to.
Expected AP to be able to expedite access to a GP. O: Hesitancy with AP follow-up.
17. Increased acceptability of the role if the service is more convenient to the patient.
Hierarchy within the professions Resource M: AP demonstrates a high-level of knowledge. (Barratt, 2016;Redsell et al., 2006;Chapple et al., 2000) Response M: Presumption that the AP must have a lesser level of knowledge. Expect the AP to carry out traditional roles. Patient mistook AP to be a GP. O: Insufficient data.
This review aimed to explore the patient views of the AP role in primary care to determine the factors that influence acceptability. The AP role was expected to be able to fill GP shortfalls; however, the sustainability of AP as a service must be questioned. The Physiotherapy UK update on the NHS FCP pilot evaluation highlighted that patients who accessed the FCP were predominantly low/medium risk (30%/58%) on the Keele STarT prognostic MSK tool (Bishop, 2019;Dunn et al., 2017). Early access to physiotherapy prevents an acute MSKD becoming more complex, consequently, patients who access physiotherapy earlier require fewer appointments (Lankhorst et al., 2017;Nordeman et al., 2006). There may be an influx of acute patients which would negatively affect access, but only initially.
This review highlighted the importance of the receptionist's role in increasing patient understanding of the AP, a similar finding to Goodwin et al. (2020). A context not identified by this review is the receptionist workload in individual practices which may influence patient awareness of APs (Morris et al., 2021).
The majority of TAs were in agreement, however, the TA 'communication' suggested that it was the illusion of time created (through communication) that is the mechanism underpinning patient acceptance of the role, as opposed to a longer consultation (TA 'Accessibility'). This is further explored in Morris et al. (2021).
A survey conducted by Halls et al. (2020) found that 41% of FCPs -the physiotherapy AP role-were prescribers, but they infrequently used the skill. This review highlighted some patients expecting prescriptions; however, this is not necessarily the intervention they will receive. Instead of dictating necessary skills, the recent AP framework outlined broad principles for delivering sustainable multi-professional teams (HEE and NHS England, 2018). Although relatively unformed as a TA, 'hierarchy' highlighted that traditional skill ownership may be undermining AP roles. Future research may explore acceptability of specific professions delivering certain skills and how patient and practice contexts may influence patient acceptance.

| LIMITATIONS
The nature of realist syntheses means that they are not repeatable as they follow realist principles, rather than set rules (Pawson et al., 2005). The involvement of a team-who each bring assumptions -influenced the formation of the realist synthesis' hypotheses.
However, a realist synthesis should not be compared to traditional measures of quality assurance; it produces recommendations, not generalisable effect sizes as its conclusions are bound by context (Pawson et al., 2005).

| CONCLUSION
The seven initial theories were supported and expanded upon, and a new TA of 'professional hierarchy' was formed. 'Previous GP experience' and 'patient perceived severity of condition' were key contexts that affected patient acceptability or the role. Receptionists may have an important role in promoting the role to patients and realigning expectations. A greater scope of practice may facilitate patient self-management and breakdown role boundaries that encourage a professional hierarchy. There were calls for future research as it was unclear which skills and interventions patients found acceptable for AP delivery.