Table 1

Programme theory for the EPaCCs study, comprising the 17 CMO statements that inform the programme theory, and the questions that will be used, in the focus group with the end-of-life board, to investigate each CMO statement

EPaCCs processCMOsFocus group questions
Commissioning1. If the strategy behind the EPaCCs is definable, deliverable and measureable, the aim, purpose and outcomes of EPaCCS will be clear. (strategy)

  • How will you evaluate EPaCCS success?

  • What are the markers of success for you?

  • What is the CCGs long term vision for the EPaCCS?

2. If HCPs engage with the EPaCCS positively on early usage and see it as an improvement on any previous EOL register, HCPs will engage positively with EPaCCS. (engagement)

  • Given that the previous EOL register was generally not well thought of, or used, how did the CCG plan to get HCPs on board?

  • How do you think the EPaCCS has been received?

Commissioning/uptake/adoption3. If the EPaCCS is well-publicised and marketed to all stakeholders HCPs will be aware of EPaCCS, understand the aim and purpose of the EPaCCS, and will initiate an EPaCCs template and/or access an EPaCCS record. (publicity)

  • How was the EPaCCS publicised and marketed to different groups of HCPs? What are your views on how effective this has been?

  • How aware do you think HCPs are of EPaCCS and do you think they understand its purpose and importance?

4. If HCPs receive sufficient support and training, so that they know how to use it, they and will initiate an EPaCCs template and/or access an EPaCCS record. (training)

  • Can you tell us about the CCG strategy for providing training and support to different groups of HCPs in the EPaCCS roll-out?

  • What do you think about this, and how effective it has been?

Uptake/adoption5. If HCPs have the time and/or resources to learn a new system, an EPaCCS template will be initiated. (time and resources)

  • There are a significant number of GP practices that have not initiated an EPaCCS – do you have any thoughts about why this might be?

  • Do you think all HCPs will have the time and resources (ie, they are connected to a computer, have internet and NHS network access) to learn and new system and access EPaCCS?

6. If HCPs are incentivised to use EPaCCS, an EPaCCS template will be initiated. (incentives)

  • Do HCPs have other ways of obtaining the information contained on EPaCCs?

  • What might these be, and are these ways better or worse, more reliable or less reliable?

Uptake7. If the patient consents to information-sharing and storage of information about their care preferences, an EPaCCS template will be initiated. (information sharing)

  • For the EPaCCS to be effective, patients must consent to information-sharing, and the storage of information.

  • Did you anticipate that this would raise any issues?

8. If HCPs are near to a computer, are connected to the internet and have access to the GP EMIS Web record, an EPaCCS template will be initiated. (access to system)

  • There is a theory that because EPaCCS is an electronic record, presently only updateable by the GP on EMIS Web, that this will have an impact on the ability of others to access it and update it and own it. Do you see this as an issue?

  • What impact do you think this might present?

9. If HCPs feel able/comfortable having ACP conversations with patients, an EPaCCS template will be initiated. (ACP conversations)

  • How do you think HCPs feel about having ACP conversations with patients?

  • Research suggests that patients with non-malignant diagnoses are less likely to be added to EPaCCS.

  • Do you think this is the case and if so why? Are there other patient groups who might be under-represented on the EPaCCS?

10. If HCPs feel that the EPaCCS facilitates, potentially difficult, ACP conversations an EPaCCS template will be initiated. (ACP conversations)

  • Some would argue that the EPaCCS template might facilitate ACP conversations with patients–what are your thoughts on this?

11. If the patient is willing, and has capacity to have ACP conversations, an EPaCCS template will be initiated. (ACP conversations)

  • Patients can only record their wishes if they are able to have a conversation with an HCP–what issues do you think this might present?

Adoption12. If End of Life Care information about a patient can be accessed more efficiently in other ways (ie, speaking with carer or reading other sources of information) the information on the EPaCCS template may not be accessed. (single point of access)

  • Are there any other sources of information that HCPs might access to establish the EOL wishes and needs of a patient and do you think they present an issue of the uptake of EPaCCS?

13. If HCPs are near to a computer, are connected to the internet and have access to the NHS Network an EPaCCs template will be accessed. (access to system)

  • There is a theory that because EPaCCS is an electronic record, presently only updateable by the GP on EMIS Web, that this will have an impact on the ability of others to access it and update it and own it.

  • Do you see this as an issue? What impact do you think this might present?

Adoption/care coordination14. If the information does not reflect the current wishes of the patient, care may not be aligned with the patients’ preferences. (patient preferences)

  • Do you feel that the EPaCCs adequately reflects patient’s wishes and preferences for care?

15. If the patient does not have clear or clinically meetable preferences, or their wishes are subject to frequent change, care may not be aligned with the patient’s wishes. (patient preferences)

  • Do you feel the EPaCCS adequately reflects the patient’s/carer’s wishes and preferences regarding end of life care and do you feel these wishes are deliverable? If not, why might this be and what needs to be improved?

Care coordination16. If HCPs access EPaCCS and consider the information contained within it to be trustworthy (current, relevant, detailed and useful) care will be coordinated by EPaCCs and this care will align with the patient’s wishes. (trustworthiness of EPaCCS)

  • Do you think the EPaCCS contains all the information HCPs need to enact their patient’s wishes and coordinate their patient’s care?

  • Do you consider it to be current, relevant, detailed and useful? If not, why might this be and what needs to be improved?

17. If EPaCCS does not enhance or improve the care that is already being delivered care may not be coordinated by EPaCCS, consistent or reflect the patients’ preferences. (patient outcomes)

  • What are your thoughts on the notion that: ‘The EPaCCS is not coordinating care, it is simply recording what is already being done’

  • ACP, advanced care planning; CCG, Clinical Commissioning Group; CMO, context, mechanism and outcome; EOL, end of life; EPaCCS, electronic palliative care coordination systems; GP, general practitioner; HCP, healthcare professional; NHS, National Health Service.