Setting.

The implementation evaluation sample included 21 general practice clinics (11 in Victoria, 10 in New South Wales) participating in the SC4C trial within the North Western Melbourne Primary Health Network (NWMPHN) and the Central and Eastern Sydney Primary Health Network (CESPHN) catchment areas.

Participant selection.

We used purposive sampling to recruit diverse providers and families/carers engaged with SC4C. Once the SC4C trial started, we invited by email all GPs and general practice personnel including practice managers, nurse practitioners, and administrative personnel to participate in a focus group discussion to explore their perceptions and experiences of SC4C six months into the intervention. Additionally, we informed GPs and general practice personnel about the opportunity of participating in a one-on-one interview with the IE researchers during and after the intervention concluded at 12 months. Participant paediatricians were not involved in focus groups but were also invited to participate in a one-on-one interview.

We recruited families/carers whose children participated in a co-consultation with a GP and a paediatrician during the trial survey intervention period by including an item seeking permission to contact them to participate in a qualitative interview about their experience. Those families willing to participate have the option to provide their details at the end of the survey. The IE researchers contacted them via phone and email to schedule this interview.

Participants recruitment was conducted between the 15^th of December of 2021 and the 17^th of February of 2023.

Data collection.

We collected data through virtual and in-person focus groups at the general practices and phone, virtual and in-person interviews. The IE researchers CCG (PhD, Research Associate, UNSW, Australia, Female) and MH (PhD, Senior Research Associate, UNSW, Australia, Male) conducted the focus groups and interviews. Both interviewers have more than five years of experience and training in qualitative research. The project managers and research assistants provided potential participants with the aims of the focus and interviews and a brief overview of the IE researchers’ professional background, interests in the area and expertise prior to their consent via email. Additionally, all participants received a participant information sheet and a consent form to sign prior to the interview. None of the participants had any preexisting relationship with the IE researchers conducting the interviews and focus groups.

We explored individuals’ knowledge and perspectives about the model of care; perceived advantages of the model of care; GP and paediatrician self-efficacy to provide care for children; barriers and facilitators; the appropriateness and acceptability of the intervention; and strategies for future implementation [32]. We designed and adapted the individual interview guides according to the type of participants (S1 Appendix). Data collection and analysis of the interviews continued until data saturation was reached [33]. We audio recorded all the interviews and focus groups. The audio recordings were transcribed verbatim by OTTER©, a secure transcription software that turns voice conversations into smart notes and keeps conversations private and only accessible to the person who owns the account. All transcripts were downloaded and deleted from OTTER© and stored in a secure drive. All participant interview audio recordings were listened to test the precision of the transcript and deleted upon completion of the study [34].

Individuals’ attitude.

GPs had a positive attitude towards working alongside the paediatrician to reinforce and keep them updated in the clinical management of children. Prior to the model GPs often felt left “out of the loop” after referring children to a specialist, citing lack of communication and feedback about their patients after they are discharged from specialist services. SC4C provided an opportunity for GPs to obtain immediate answers to queries about paediatric care and to obtain timely comprehensive information regarding the treatment of their paediatric patients after the co-consultation. Most GPs also commented on families’ attitudes towards the SC4C model and their receptiveness to seeing the specialist during the co-consultation, which provided families a sense of reassurance in the care they were receiving. Overall, families across the sites expressed their satisfaction with the service received. Families felt involved and able to ask questions during these co-consultations, enhancing their confidence in the care received for their child. Paediatricians’ overall impression towards the SC4C model of care was that it reduced the “gap” between hospitals specialists and GPs.

Intervention coherence.

While the SC4C model was reportedly well integrated within participating general practices, there were some instances in which practices desired more clarity around the logistics of the model and the expectations placed on practice staff. More often than not, practices eventually became more familiar with the processes and expectations of SC4C over time. Additionally, practices whose implementation started later in the stepped-wedge trial reported a smoother implementation experience, largely due to the increased experience of the study team to communicate expectations effectively. Participants reported variation in their experience with the implementation of the model and its different components.

Most GPs understood that the paediatrician’s role during the co-consultations was to support and provide guidance to enhance GPs’ capacity to provide care to children. However, paediatricians reported variability in how GPs approached these co-consultations. In most cases, GPs tended to discuss the cases with the paediatrician before entering the consultation room so they could come to agreement on how to manage the child’s condition. However, some GPs, according to paediatricians, were not as prepared as others, using a more passive approach allowing the paediatrician to guide the consultation while sitting back observing and taking notes.

Case discussions were designed to provide paediatric education on clinical cases and best practice guidelines resources and information. GPs understood the objective and got familiar with the format of the case discussions. The case discussions served as an opportunity for gathering the general practice staff, regardless of their enrolment and engagement with the delivery SC4C model of care, to share knowledge and experiences. Paediatricians reported overall high attendance at these educational sessions and mentioned they tried to adjust them according to the needs of those attending.

Phone and email support was included as a component of the model of care to provide additional support and advice outside the consultation and case discussions time. Although GPs were aware that they could access this support, some GPs reported being unsure how to use this resource. The uptake of this component of the model of care was variable. GPs felt that phone support was not particularly needed while the paediatrician was regularly visiting their practices. However, many GPs cited phone and email support as a resource to use for ongoing support in the future. This was reinforced by the feedback obtained from the findings of our study from a few GPs who felt that just having phone and email support would be equally valuable.

Close collaboration/enhanced understanding.

Overall, GPs expressed their satisfaction with having SC4C as a collaborative model enabling the provision of care for children alongside paediatricians. This close collaboration allowed paediatricians to better understand the differences between hospital and primary care and helped to close the gap in collaboration between practitioners in these settings. GPs and paediatricians commented that the physical presence of paediatricians in GP practices was key to building engagement and collaboration. Some paediatricians commented that they felt like the in-person representative of hospitals, enhancing the collaboration across primary and tertiary care.

Trust-based relationships/rapport building.

Having this direct contact with the paediatrician facilitated the establishment of trusting relationships. GPs reported that more informal “corridor conversations” in their practices regarding their paediatric cases as one of the most valuable components of SC4C. Families also reported rapport and relationship between the GPs and paediatricians was evident during the co-consultations. Some GPs resented the feeling that they were merely a gateway along a referral pathway to a specialist rather than the solution for the needs of the family at the beginning of model implementation. However, the physical presence of the paediatrician onsite helped foster rapport and trust, and enabled GPs to understand the value of their role and feel part of the process when caring for children.

Telehealth.

In response to the COVID-19 pandemic, general practice shifted their model of care to provide care via telehealth as the risks of the pandemic hindered the provision of face-to-face co-consultations. Participant GPs reported that telehealth co-consultations were challenging during the pandemic due to the difficulties conducting physical examinations and a preference for face-to-face communication with paediatric patients and their families.

Learning and professional development.

Learning and reinforcement of essential skills, including how to interact and communicate with children and their families, examinations, early detection of behavioural and developmental concerns, and referral pathways, among others, were appreciated by GPs. A few GPs felt the model was more beneficial for their learning and professional development rather than for their patients. This perception arose from the fact that while paediatricians offered guidance and support during co-consultations, they were not directly involved in subsequent patient follow-up care. As a result, paediatric patients still required referrals to other specialists post-consultation.

Regarding the GPs’ referral patterns, both GPs and paediatricians agree this experience would probably not necessarily reduce the number of referrals but would improve the quality of those referrals instead. Paediatricians reported GPs referrals, in most instances, were justified. Thus, the paediatrician’s role was to assist them in providing more comprehensive information regarding those referrals. Additionally, paediatricians felt their role in SC4C has been helpful in raising GPs’ awareness of available resources for children that families can access while waiting to see a specialist. GPs supported this by saying they now have additional resources to provide families with additional information and advice. On the feedback survey, a GP commented that while still needing more confidence in managing specialised conditions, the SC4C model was useful for becoming more informed about those conditions and gaining knowledge regarding other options to manage their paediatric patients. GPs and PMs commented on the benefits this model of care offers to their patients allowing them to obtain support and immediate answers to their questions. Some families also highlighted the importance of professional development of their GPs as part of this model of care, which improved their confidence and reassurance in their GP’s skills to manage their children.

Confidence building.

Most families cited that they had built rapport and trusted their GPs before this model of care. However, some families still reported that they would prefer to visit a paediatrician for their child’s condition in the future. From the GPs’ perspectives, they valued and cited improvements in their confidence because of participating in this model care. GPs’ perceived capability and knowledge to manage paediatric patients influenced their participation in SC4C. Some GPs expressed feeling vulnerable to being exposed to the “expert opinion” of paediatricians. In some instances, feeling afraid to be judged was reported as a motive negatively influencing the enrolment or engagement of some GPs in SC4C. Nevertheless, most GPs expressed that the paediatricians’ interpersonal skills were crucial to making them feel comfortable and able to ask questions.

Access to quality care.

The accessibility to specialists provided by SC4C was overwhelmingly noted as a key benefit by GPs and families. The long waiting times to visit a private paediatrician was a significant problem that families across both states dealt with. In more affluent versus poorer areas with greater availability and access to private paediatricians, participants still reported a preference to have access to co-consultations in the long term due to the improved access to quality care with the expertise of both GPs and paediatricians.

From the perspective of families, having direct access to a specialist without paying extra fees was an incentive for them to participate in the co-consultation. For this reason, they expressed they would like to have access to this service in the future even if the continuation of the service means for them to pay an extra fee.

Perceived need.

Those GPs that were less likely to engage with the model cited a familiarity with managing children, not seeing the need to involve the paediatrician. Most GPs expressed they would like to have the paediatrician onsite for a more extended period. However, they still felt they could manage their paediatric patients, and having the paediatrician there has reinforced their self-efficacy in the area. While most GPs cited positive family attitudes, some GPs mentioned family unwillingness to attend a follow-up consultation with the SC4C paediatrician when their needs had already been met in a consultation with their GP, or they preferred to visit their own private paediatrician.

Financial burden.

General practices are under considerable strain due to the workload, staffing levels and different billing models relying on the number of patients seen per hour. Therefore, the implementation of this model of care can be seen as an additional pressure for them. While each general practice was paid for their participation in the model of care, GPs in this study did not directly receive any financial incentives, so they relied on their usual source of income. When asked about the financial impact of delivering the model of care, most participants cited no significant changes in their revenue, however some cited a drop in their ability to bill effectively. While potentially costly, GPs felt that the shared experience and the learning component of the model offset the potential drawback in cost.

Perceived effort.

The paperwork and administrative burden to set up the SC4C model hindered initial implementation. In the first practices in which SC4C was implemented, practice managers expressed feeling overwhelmed about the amount of correspondence received from the research team. While not cited as an issue by all practice managers and GPs, this was an issue that proved a pivotal challenge for some practices, reducing their engagement with the study team and model. Adapting the SC4C model to the different circumstances of the general practices was highlighted to ensure effective scale up of SC4C. Some GPs expressed feeling a bit “pressured” by the formality of “having to reach” specific numbers of booked co-consultations. There were also difficulties around aligning paediatrics visits while GPs were onsite and scheduling the one-hour case discussions between GPs and paediatricians due to the high workload of GPs.

From paediatricians’ perspectives, the most significant burden was the time spent driving between practices and the number of practices (up to five) they visited at some points during the implementation. Paediatricians felt the SC4C model was highly dependent on their energy to engage and motivate GPs, which was an additional challenge when they had to visit several practices at once. As a suggestion for the future, they recommended visiting several practices located closer together, or reduce the number of practices to visit per paediatrician.