1. Sick or what? A social constructivist view of collective knowledge transformation in primary care practice John Gabbay Andrée le May KT08 Banff June 2008

2. 2 Levels of knowledge translation 1 Centre/ EBP / KT 2 Local policy 4 Patient 3 Clinician

3. 3 Level 1: (e.g. the “Evidence-based..” movement)

4. 4 Gabbay, le May, Jefferson et al: Health 2003 Vol 7 283-310 Level 2: Policy group processes

5. 5 Level 3: The clinician Patient’s view Practitioners’ “mindlines” General Individual Gabbay, le May, BMJ 2004;329:1013

6. 6 Mindlines are: –internalised collectively reinforced tacit guidelines-in- the-head that clinicians use to guide their practice –one person’s mental embodiment of their knowledge- in-practice –linked socially and organisationally to other people’s mindlines

7. 7 Other worlds Clinical worldResearch world S ocialisation E xternalisation I nternalisation C ombination Research based knowledge Centre (eg DH) Patients Industry explicit knowledge tacit etc…. SECI (Nonaka & Takeuchi 1995) explicit tacit knowledge information potential for use as “knowledge in practice” Gabbay 2008 (in press) KT

8. 8 The story so far: 1 3 2 Pt Centre/ EBP/ KT Local policy Clinician

9. 9 Design and methods Practice: “Lawndale” –8-partner GP practice plus 3 nurses and others –leading-edge practice –small UK rural seaside town Ethnography: –2 years surgeries, clinics etc; –nearly 7 years formal/ informal practice meetings –observation (participant/ non-participant) –interviews open/ semi-structured individual/ group/ multi-professional informal discussions / chats Brief “check” ethnography in an urban practice Thematic analysis

10. 10 One finding: multiple roles of GPs, e.g.: clinical domain managerial domain public health domain professional domain diagnosingmanaging resources, personnel and logistics disease prevention keeping up to date prescribingmonitoring and improving quality screeningreviewing practice investigatingdeveloping the IT systemhealth promotionteaching and training advising and explainingcomplying with contractual and legal requirements health educationnurturing collegial networks referringhandling the Primary Care Trust disease surveillancepromoting general practice (e.g. ’ union ’ work) advocatingtraining practice staffknowing the local district sustaining credibility

11. 11 This phase of ethnography (2005-7) Monthly practice meetings (multi-professional) Aimed at meeting requirements for new GP contract

12. 12 The GP contract to implement new practice in chronic kidney disease (CKD) For maximum remuneration for managing CKD: Produce a register of all their adult patients with stages 3-5 of CKD (i.e. with an eGFR of <60ml/min/1.73m2) >90% have record of their blood pressure >70% record blood pressure <140/85 >80% of CKD registered patients with hypertension on appropriate treatment or good reason why not.

13. 13 Transferring knowledge via new contractual arrangements (a caricature)

14. 14

15. 15 Conclusions “Knowledge in practice” = “mindlines” Multiple cues to amend mindlines Little direct translation of new knowledge (SECI) Social, collective construction of mindlines Mindlines structured, shaped, sustained by contextual demands, opportunities, constraints Linkage between roles, goals, activities and knowledge-in-practice (missed by this KT) The roles being played influence the way the mindlines are “laid down” and used CKD is being reconstructed by this process Gabbay J, Le May A. In: (Ed) le May A. Communities of practice in health and social care 2008. Oxford: Blackwell (in press).

16. 16 Implications for KT Forum: Individuals tend to work and learn collectively (e.g. in communities of practice) They transform knowledge, not translate it, constructing knowledge-in-practice that suits their complex, multi-role needs Inevitably subversion, therefore, of “top- down” KT if it doesn’t suit those complex needs (as also happened with most top-down guidelines in our study…) Individuals’ use of knowledge-in-practice needs to be the driving force of KT KT needs to start by understanding the recipients as active agents