Understanding and improving compound pressures in general practice: a realist review, appreciative inquiry, and three embedded studies within a review

Project aim: to conduct a realist appreciative inquiry (AppI) and realist review about compound pressures (CP) affecting general practice and the delivery of effective and equitable patient care.

Research questions: How, why, when, and in what circumstances might CP be addressed in general practice to maximise effective and equitable patient care? Specifically, within the available literature: What are the characteristics of CP in UK general practice? What are the reported general practice solutions to CP?

What are the intended/unintended outcomes for general practice to CP interventions? How can general practice support approaches to CP? How can patients and the public work with services to approach CP in general practice? In addition, three SWARs ask: What is the value of an AppI approach to inform initial programme theory (IPT) development for a realist review?

How does use of ‘key’ relevant data, rather than comprehensive data extraction/analysis from all included documents affect the outcomes of a realist review?

Can Artificial Intelligence (AI) technology be used in future realist reviews to support the identification of key papers, and/or programme theory (PT) development?

Background: CP and our responses to CP affect human health. For example, climate change (e.g. heat waves, floods, migration); pandemics; war/financial crises (e.g. energy availability/costs). CP can be predictable and pre-determined, and/or unpredictable/new in nature or scope.

Various strategies and solutions have been proposed to maximise capacity to address CP generated needs. These range from specific short-term initiatives, through to buffering existing systems (e.g. general practice) to ensure flexible and agile resources. Interventions designed to prevent, identify, and manage CP may have intended and unintended consequences.

These depend upon how, when, and if something is named as a CP; what response this may produce (e.g. financial support, extra staff, patient redirection to additional/other services); and whether this is a short-term, or sustained approach.

Methods and Timelines: WP1 01.01.2025 (0-5 months): Realist Appreciative Inquiry (AppI) to maximise PPI and stakeholder input into the review scope, focus, and IPT development. AppI aims to facilitate positive change by discovering and elevating individuals’ assets, successes, hopes, and dreams (1). This framework enables research to focus not only on identified problems, but in addition identify: ‘what is working; why is it working; and what could be in the future?’.

WP2 02.06.2025 (6-19 months): Realist Review with empirical and grey literature building on WP1 IPT and identified priorities, approaches, and solutions. This project includes three elements of methodological innovation (SWARs) alongside following RAMESES guidance (2). First, evaluation of how AppI can inform IPT.

Two further SWARs will examine how AI might contribute to identification of a) key data (and related impact on ultimate review knowledge claims) and b) PT development. We will continue connections with our PPI and stakeholders throughout, to inform dissemination and maximise relevance to policy and practice.

WP3 03.08.2026 (20-26 months) Dissemination and Impact. Two events with relevant public, practitioner, and policy participants to co-produce resources and recommendations about a) future CP strategies and interventions and b) how SWARs can inform future realist methods. These will inform outputs (e.g. short reports, academic papers) for policy, practitioner, and public audiences.