Implementation of a SNAP intervention in two divisions of general practice: a feasibility study

Project officers approached 100 practices, of which 21 agreed to participate in the evaluation (10 urban and 11 rural practices). This included two solo practices, nine with 1–5 GPs, and 10 with five or more GPs. A practice manager was employed at 18 practices and practice nurses in 16 (most part-time). All participants were provided with information sheets and signed consent forms.

The study was approved by the University of New South Wales Human Research Ethics Committee.

The DGPs provided the full intervention to 21 practices and motivational interviewing training to 42 additional GPs. Intervention costs to each DGP averaged $34 537, mainly comprising part-time project officer salaries and training costs.

SNAP risk factor recording and electronic file management was maintained in 18 of the 21 practices. Recording was least frequent for physical activity, and this did not change significantly after the intervention. Although 13 practices had recall systems, none was used for SNAP. After implementing the SNAP program, eight practices had commenced recalling patients for SNAP risk factor interventions.

While 16 practices had SNAP materials on display in waiting rooms, only two of the 10 urban practices had educational materials on alcohol. The proportion of practices with display materials on physical activity increased after the intervention, as did the proportion with a designated staff member to coordinate patient education materials.

Some SNAP referral services were available to all practices, but nutrition referral services tended to be private or fee-based in rural areas. Aboriginal Medical Service referrals were predominantly internal. Access to physical activity referral services improved in the urban division but deteriorated in the rural division, due to the departure of an exercise physiologist during the implementation period.

Participants in the in-depth interviews reported difficulty making the organisational changes required to incorporate SNAP into the practice as a whole (quotes in the following text are from GPs).

One of the DGPs reported that this problem related, in part, to the lack of practice meetings, case management conferences, effective communication and teamwork. GPs were the ones predominantly involved in implementing SNAP, with administrative staff adopting an important role in follow-up and referrals. Although there was an opportunity to involve practice nurses in the SNAP program, especially in the rural division, there were in fact few changes to nursing staff roles. This was largely because of competing demands from other activities for which they were specifically funded (eg, immunisation, wound care and health assessments).

Other barriers included a lack of time and heavy workloads. The SNAP intervention required proactive planning. In each consultation, GP time was required to assess and record SNAP risk factors, undertake motivational interviewing and advise treatment, particularly for overweight and nutrition problems. Staff time was also required to arrange referrals, follow-up, recall and reminders.

The absence of specific funding required that the SNAP intervention had to fit in or compete with the patient’s presenting problem in the consultation. Although long consultations are better remunerated, payment is not commensurate with the increased time. No additional staff costs are covered.

In addition, patient motivation associated with stress, depression and physical illness affected the priority that patients placed on changing behaviour. In patients with these types of problems, GPs offered medication, structured problem-solving or referral. GPs said they feel satisfied and rewarded when people make changes, but frustrated when they do not.

Access to referral services was sometimes problematic for patients in terms of cost, transport and waiting lists, unless they had private health cover. There was only limited access to public nutrition services and to counselling for at-risk alcohol drinkers (with services focused on the more dependent and complicated cases). As noted by one of the DGPs, despite efforts at liaison with referral agencies, problems with communication and feedback remained.

GPs who had previously conducted SNAP interventions found participation and ensuing DGP support gave them encouragement and confidence to sustain SNAP management. Many GPs also reported that the motivational interviewing workshop was helpful.

All GPs felt that, overall, the SNAP interventions reinforced their clinical skills and had a positive impact on their patients.

In interviews with DGP and AHS staff, both stressed the importance of the memorandum of understanding between them, the establishment of local planning committees and the commitment of staff time to the successful implementation of the program. However, this partnership was not at the most senior levels of the AHSs, and this affected the development and planning of more effective referral pathways — especially for dietetic and drug and alcohol services, which were less developed than those for physical activity.