This report provides a snapshot of both the quality improvement (QI) work being undertaken in practices across the UK and the views of GPs and practice managers about the facilitators and barriers to improvement. Despite concerns expressed in policy statements and the media about the pressures that general practice is under and the impact of these pressures on practices’ ability to deliver high quality care, our data show that the majority of GPs and practice managers believe that improving the quality of the services they provide is an important activity. Only a very small number who responded to our survey were not involved in any QI work.

‘Working as a team’, ‘good clinical leadership’ and ‘clinical staff have the skills to assess quality’ were the key facilitators for improvement identified in the survey results. The importance of the practice manager as part of the management team was also highlighted. The smaller size of many practices means that the leadership is in much closer proximity to frontline staff, and GP partners remain, in a sense, front-line staff themselves, seeing patients on most days. This creates the potential for good working relationships and a positive QI culture. Indeed, it is clear from the responses to the surveys that both GPs and practice managers think that all members of the practice team, clinical and non-clinical, are and should be involved in improving the services that the practice provides. Furthermore, most respondents also reported that there was no single person responsible for leading improvement work; instead this depended on the activity in question.

Another trend is towards greater joint working. Practices were already beginning to work together, in advance of the requirement in the NHS long term plan that all practices should be part of a PCN. In free text comments on the survey, many respondents indicated that they were either working towards a federation or had informal links with other practices. Such contact across and between practices should have a positive impact on QI efforts in individual practices.

How can practices be better supported in quality improvement work?

Practices identified a range of areas that enabled and obstructed efforts to improve the services they provided. Some of the barriers identified will clearly have an impact on a practice’s ability to improve its services, for example staff shortages. Yet most practices were able to identify ongoing improvement activities. It is notable that while there were demands from external agencies for QI, most of the improvement work had been generated from within practices. So, whatever the current barriers are, improvement work is happening in spite of these barriers. Nevertheless, the survey results suggest some ways in which practices can be better supported to pursue QI work.

Data and data analysis

Data and data analysis are clearly important to QI and this was acknowledged in our data. Over 40% of GP respondents reported that they did not feel they had access to the necessary data and skills (Table 3.4), and this was supported by the interviewees, who reported that they lacked the time to gather and analyse data. It may also be the case that there is a lack of basic data capture and analysis skills in practices. As more data becomes available and general practice IT systems become more sophisticated, practices need to have the skills to make use of them in QI work, or have access to external expertise, such as analysts employed by integrated care systems or clinical commissioning groups in England.

Quality improvement skills

While many GPs and practice managers in our survey had been trained in Audit and Significant Event Audit, there was a lack of knowledge about other QI tools. Few GPs or practice managers report that they use other tools, such as PDSA Cycles or Root Cause Analysis (Table 4.1), and similarly small numbers indicate that they have received any training in these QI tools (Table 4.2). On the positive side, there is an appetite for and interest in receiving training in a wider range of tools (Table 4.3), although this will bump up against the difficulties of GPs and practice managers finding time for training and the lack of protected time for improvement. With the advent of PCNs (England) and GP Clusters (Scotland) there is clearly potential for practices to share skills and capacity in this area.

Support from external bodies

Most GPs did not think that they had enough resources to improve services and the care provided (except in practices with a list size of over 20,000 patients, where respondents were evenly divided over whether the practice had enough resources). Nevertheless, the survey also found that, when it comes to QI, external resources to support change were generally not seen as particularly helpful because of the extra workload they can generate (Table 3.1). What is clearly missing in general practice is support from outside to create space and time for practices to get together as a complete team to learn, identify and plan improvement. This is partly a product of the way general practice is structured as a series of relatively small independent organisations. In this respect, the impact of the different organisational form of general practice compared to the larger organisations of secondary care, with their accompanying organisational infrastructure and formal training policies, should not be underestimated. Also, unlike secondary care, there is no formal requirement to ensure that protected time is provided, although the Scottish NHS has recognised its importance., Furthermore, on occasion, the bodies that commission and oversee individual practices can actively work against attempts to create time when the practice can meet and work on QI activities as a team.

So, alongside steps to tackle workforce and funding pressures, support to help practices create time for improvement and vigilance to minimise external reporting requirements will be particularly important ways in which the wider system can support general practice in QI.

It is perhaps remarkable that in a UK-wide study of both GPs and practice managers there is such a high level of agreement (across different countries as well as between GPs and practice managers), with only minor variations, about what hinders work to improve services and what supports it. NHS bodies with commissioning, regulatory and support functions across the UK need to acknowledge the QI activity already being undertaken in practices and take practical steps to support practices in the work they are already, willingly, undertaking.

The 2018 General Medical Services Contract in Scotland states that ‘from April 2018, each practice will receive resources to support one session per month for Professional Time Activities. There is a clear intention to achieve, over time, regular protected time for every GP’.

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