Barriers and facilitators to learning health systems in primary care: a framework analysis

Discussion

In our original study, we presented a case study of an LHS within an Australian primary care setting and showed that it was operating within several dimensions of the LHS framework, and that its staff were willing to embrace additional elements of the LHS.24 In this secondary analysis, we used the TDF to describe barriers and facilitators to converting this willingness into reality. In all LHS domains there was a consistently reported influence of environmental context and resources; for example, the MQGP affiliation with a university was described as a strong facilitator of learning, and the unique general practice environment was reported to shape patient–clinician partnerships. The professional role of participants was a second consistently reported determinant, influencing access and attitudes to learning and incentives. The reported impact of other determinants varied across LHS dimensions; for example, continuous learning culture was mediated by social influences, where strong social relationships were reported to facilitate informal learning, while a lack of knowledge of clinic structure and governance was described as a barrier to its effectiveness. Overall, our results show that implementing the principles of an LHS in this primary care setting was influenced by many behavioural determinants, some applicable to healthcare in general, but most specific to the general practice structure and environment.

A key strength of the study was its codesign, which allowed it to reflect the goals of both the research team and the staff of MQGP. Further strengths included the high participation rate and broad recruitment strategy, which enabled a comprehensive description of behavioural determinants from the perspective of clinical and non-clinical staff. Additionally, this secondary analysis was conducted by an IAT that did not participate in the original study and were thus less subject to biases from their relationships with practice staff or from the original interviews. The primary limitation of this study was the inclusion of only one organisation, limiting the generalisability of our results to other primary care settings. Generalisability is also limited by the affiliation of the practice with a university which, while a facilitator of the uptake of LHS principles, is relatively uncommon in the Australian context. A final limitation was the timing of the present study, which was conducted during and after significant public health restrictions associated with the COVID-19 pandemic. These restrictions, and their removal, would likely have influenced the responses of participants.

Despite these limitations, our results have encouraging similarities with the few other empirical investigations of primary care LHS that are grounded in implementation science.19 Pestka and colleagues qualitatively evaluated the lessons learnt from their implementation of a primary care LHS in the USA.27 They, too, reported that clearly defined roles and the incentivisation of value-based care were facilitators to the development of an LHS, as was the use of a weekly newsletter to communicate essential information. However, their investigation took place in a system of 40 primary care practices, much larger than the two practices described in the present study. The facilitatory effect of a weekly newsletter was diluted by a larger LHS size, where at times people had ‘no idea what was going on at other stations’,27 a finding that was echoed by another investigation of a province-wide primary care LHS in Canada.28 The same study also reported that the perceived difficulty or cognitive load of a technology was a primary barrier to its use, and that a perceived increase in the quality and efficiency of patient care was a motivation for participants to engage in the LHS,28 findings similar to our results. However, a key difference between their investigation and our own was the type of incentives that motivated participants; in the Canadian province-wide primary care LHS competition or peer pressure were motivators for engagement,28 while our participants reflected that they were primarily motivated by the rewards of providing better patient care and developing a sense of comradery with their colleagues. These differences may reflect the different social contexts in which the studies were conducted, particularly the influence of the COVID-19 pandemic, in which healthcare workers likely banded together to deal with high levels of uncertainty and stress.

The results of our own and other empirical investigations suggest that while some barriers and facilitators are unique to certain contexts, others are common to many journeys towards a primary care LHS. These are summarised in box 1, which also describes possible strategies for primary care practices to facilitate their journey towards an LHS. A notable facilitator that likely applies to all contexts is external support, as many primary care providers work in small independent community practices which limits their access to resources.29 Affiliations with academic and professional institutions, including the use of codesign and embedded researchers, or collaborations of multiple primary care practices are viable strategies that cultivate a primary care LHS. Additionally, our results suggest that it is not only patient–clinician partnerships that are important in the primary care LHS, but rather that administrative staff also play an important role in the patient experience. As such, primary care practices that aim to become LHS should invest in training, involvement and retention of all staff, not just those in clinical roles.

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