Foreword and commentary

About this report

In the past decade, interest in the use of quality improvement (QI) approaches and tools in general practice has grown markedly.,,,, However, while the profile of QI in general practice is on the rise, there is very little concrete data about the extent of knowledge and implementation of QI approaches within practices. In fact, not much has changed since Paresh Dawda and colleagues highlighted the lack of data on QI in the sector almost a decade ago.

The research by the London School of Hygiene & Tropical Medicine (LSHTM) summarised in this report aims to help close this gap. Based on a survey of over 2,300 GPs and over 1,400 practice managers across the UK conducted in the second half of 2017, along with interviews and other qualitative research, it provides a valuable insight into the level of QI awareness, appetite and activity in general practice. It comes at an important moment in the development of QI in general practice following the recent inclusion of a QI domain in the Quality and Outcomes Framework (QOF) and the establishment of primary care networks (PCNs) in England to support service transformation and improvement, mirroring developments in other countries in the UK. Meanwhile, the Royal College of General Practitioners (RCGP), which argues that QI is now ‘fundamental to general practice’, is stepping up its efforts to raise awareness of QI in practice teams through its QI Ready online learning platform.,

The role of quality improvement in general practice

At a time when GP practices are struggling to recruit and retain GPs and other staff in the face of growing demand and constrained resources,, the use of QI approaches provides practices with a means of driving up both the quality and efficiency of their service. While there are a range of methods and tools designed to improve quality, QI involves a structured approach to tackling complex problems. It offers practices the chance to free up capacity and time by tackling constraints, delays, duplication and other problems in their care processes and pathways. It allows them to take a step back and look with fresh eyes at the service they provide, and the tools they need to do things differently., And because QI works best when it is a team enterprise, it can help to capitalise on the talents and energy of the whole practice team and, in doing so, improve morale and confidence. Moreover, it gives patients the opportunity to get involved in shaping and testing the services they use.

The technical and relational skills that practice teams will gain from engaging in QI will also stand them in good stead when it comes to making the most of new trends in care delivery such as patient-to-professional telehealth, remote monitoring and online patient portals. In addition, by strengthening their QI capability, practices will be better equipped to deal with developments in other care sectors likely to have an impact on demand for GP services, such as the proposal in the NHS long term plan to redesign outpatient services with a view to avoiding up to a third of face-to-face outpatient visits in England.

As well as helping practices to improve their own services and processes, QI approaches can be used by practices to drive improvement on a collaborative basis. For example, they have been used to identify and tackle variations in service delivery and outcomes between neighbouring practices., Working in partnership also enables practices to pool improvement capacity and capability and to share insights and learning. Opportunities for such collaboration will undoubtedly increase over the next decade across the UK as formal and informal partnership working between practices through networks, federations, alliances and clusters becomes the norm.,

At national level, too, there is growing appreciation of the critical role that QI can play in helping to sustain and strengthen general practice. As highlighted above, a QI domain has just been included for the first time in the QOF in England, while in Scotland a network of GP Clusters has been set up, in part to encourage GPs to take part in QI activity with their peers. Quality improvement has also become an intrinsic element of GPs’ learning and professional development: GPs are now expected to engage in QI activities as part of their postgraduate training, appraisal and revalidation, – although there has been relatively little analysis of the type of activities that have been carried out and the impact they have had.

Background: The challenges and opportunities for delivering quality improvement in general practice

Of course, QI is no instant panacea. Doing it well requires time, perseverance and a supportive context. Not only do practice teams have to spend time getting to grips with the problem they are trying to solve (it is easy to make the wrong assumptions about the nature, scale and root cause of the problem), but they then have to test and iterate their proposed solution over time. Finding such time is becoming ever harder for many practices, and it is easy for improvement to become crowded out by more pressing day-to-day issues. And then there is the question of culture. Some of the biggest barriers to improvement in health care are the entrenched professional hierarchies, which make it hard for staff from different professions, grades and levels of seniority (let alone with patients) to hold open and inclusive conversations about improvement., General practice has been no exception. So, it is not enough to introduce practice staff and patients to QI approaches and tools and to give them the chance to use them. Without a culture of collective leadership for improvement,, any improvement effort is likely to fall short of its intended outcomes.

Nonetheless, general practice does appear to have some distinct advantages when it comes to QI. Firstly, practices’ status as small independent businesses lend them an agility and responsiveness that can be hard to find elsewhere in the health and social care system. Secondly, the size of the practice team is usually small enough for people to get to know each other reasonably well, and to understand what may motivate staff to get involved in improvement (or discourage them). It also makes it possible to involve each professional group and function within the practice in the planning and delivery of an improvement intervention. Thirdly, as community hubs closely connected to the local population they serve, GP practices are well placed to involve patients and other community groups in the design and delivery of improvement interventions. Fourthly, the fact that general practice has been almost completely digitised has given practices looking to undertake QI a major advantage over providers in almost every other health care sector, most of which are a long way behind general practice. The ability, for instance, to extract and analyse the patient information held in GP electronic health records (EHRs), gives practices the means to compare treatment uptake, adherence and outcomes within specific patient cohorts and to use it to identify areas for improvement.,

The research findings

The LSHTM research found that most GPs and practice managers see QI as a core aspect of their work. Almost all of them (99%) reported that their practices were involved in some form of QI activity and, for most of them, the driver for this work came from within the practice rather than from external prompts. Furthermore, many respondents (60% of GPs and 71% of practice managers) said they were working collaboratively with neighbouring practices to improve services. Another significant finding was that many practices did not have a single, designated improvement lead, and were sharing the responsibility out across the practice team. In many cases the task of leading improvement was determined by the nature of the problem and the skills needed, which implies an inclusive and non-hierarchical approach to improvement.

But the LSHTM team also found plenty of issues that are making it difficult for practices to deliver improvement. As well as the twin challenges of high patient demand and staff shortages, the level of external demands (such as reporting requests) and the time needed to handle them was a source of frustration for nearly all respondents: 95% of GPs and 93% of practice managers identified the demands of other NHS agencies as a key barrier to improvement. The lack of protected time to plan and design improvement (a key difference from QI in secondary care) also emerged as a major challenge for almost 80% of GPs. This is an important finding. As the improvement programmes supported by the Health Foundation over the past decade have shown, it is almost impossible to embed and sustain an intervention without careful reflection and planning upfront. Improvement teams that try to cram the planning of a complex intervention involving multiple processes and people into a few brief impromptu meetings held between clinical commitments will struggle to make an impact.

Another challenge highlighted by the research is the level of improvement capability within general practice. For example, only 20% of GPs and 33% of practice managers were familiar with Plan, Do, Study, Act (PDSA) Cycles, which is perhaps the most widely used improvement approach in health care. Meanwhile, 42% of GPs and 51% of practice managers identified a lack of skills in managing and analysing data as being a barrier to improvement in general practice. On the plus side, the survey shows that 64% of GPs and 73% of practice managers would be interested in training in a wider range of QI tools and approaches. However, while their appetite for training is clear, it is less certain how they currently would find time to undertake it, given how little time they have for non-clinical responsibilities.

Implications of the research: The need to create an environment conducive to quality improvement in general practice

A great deal hinges on the extent to which it is possible to carve out dedicated time for QI in general practice. The goal must be to create an environment in which all practice staff are encouraged to learn about and participate in improvement, and where the resources exist, to cover their day-to-day clinical or administrative roles while they do. Up until now, such a culture has been the almost exclusive preserve of the secondary care sector, with primary care examples thin on the ground.

The opportunities mentioned above for greater collaboration between practices across the UK offer some scope to address this imbalance. But it will only happen if QI is central to the design and delivery of these partnerships and not relegated to the margins. At the very least they need a vehicle for sharing existing improvement capability and learning between participating practices and pulling in innovative ideas from elsewhere, such as the Q Community, the Royal College of General Practitioners’ QI regional champions or NHS England and Improvement’s Primary Care Improvement Community. Formal partnerships should also put in place a plan to identify and address any capability gaps, coupled with the means to coordinate and support improvement work carried out within and between member practices.

Of course, only so much can be done without national, regional and local support. Policymakers and system leaders have a responsibility to ensure those working in general practice are able to improve the quality of the services they provide by helping them develop their QI and data skills. They also have a role to play in helping practices carve out the time needed for QI: as the authors of this research observe: ‘... alongside steps to tackle workforce and funding pressures, support to help practices create time for improvement, along with vigilance to minimise the additional burden of external reporting requirements, will be particularly important ways in which the wider system can support general practice in quality improvement.’

In England, the General Practice Development Programme, which aims to help build the capacity for improvement within the sector, is a step in the right direction. The proposal in the NHS long term plan to increase the number of integrated care systems (ICSs) building improvement capability is also encouraging – providing that this support filters through and provides tangible benefits for practices on the ground. However, given how far general practice still has to travel if it is to come close to matching the level of improvement capability in secondary care, these kinds of support will need to be maintained for some years yet if they are to have a meaningful impact. The case for doing so will become stronger as more examples of successful efforts to build improvement capability at scale within general practice emerge, such as Enabling Quality Improvement in Practice (EQUIP) in Tower Hamlets and Clinical Effectiveness Southwark, recent projects supported by the Health Foundation that are described further in Appendix 3. These examples show what can be achieved in the right context with a long-term vision, strong leadership and sustained investment over time. Given that general practice is not only responsible for the vast majority of patient contacts in the NHS but is also central to efforts to deliver new models of care and population health management, it is time for QI in general practice to receive the attention and support it deserves.

Bryan Jones Improvement Fellow

The Health Foundation

Previous Next