Introduction and background

Aims and structure of this report

This report presents the findings of a research project that aimed to establish what quality improvement (QI) work is currently being undertaken in general practice and by whom and to explore the extent to which the infrastructure and management of general practice in the United Kingdom (UK) has the necessary capacity and capability to support QI. The data were gathered through two online surveys, one of GPs and one of practice managers across the UK, preceded by a series of qualitative interviews.

The first section of this report includes a brief overview of the context of QI in general practice and a description of the project methodology. The project results are then presented in the sections that follow. Section two looks at what motivates practices to improve quality, the main areas in which practices undertake improvement activities, how improvement work fits into the practice workflow and who in the practice is involved. Section three explores the barriers and facilitators to improvement, while section four examines the level of GPs’ awareness and use of different QI approaches and tools.

The context of general practice quality improvement

90% of all patient contacts in the NHS occur in general practice. It is the key gatekeeper to other services as well as being the main provider of community-based health care. In England, general practices have long been at the heart of changes to the way health services are commissioned and delivered. In recent years, smaller practices have joined together into ‘super-practices’ (although these are still relatively few in number) or, more commonly, federations, to take advantage of the possibilities provided by working at scale, such as the ability to share data across practices to enable improvement. In line with plans outlined in the NHS long term plan practices have formed multidisciplinary PCNs with other services and neighbouring practices. Unlike existing federations or informal networks, these will be both formal and contract-based, with new and existing funding (for example, funding for enhanced services) flowing into them. The NHS long term plan follows on from the General practice forward view, which outlined ways that general practice can be supported and improved. This in turn followed the Five year forward view (FYFV) for the NHS in England published in 2014. Like several previous policy initiatives,, the FYFV had a focus on moving more aspects of care out of large hospitals and into a primary care setting, mainly general practice. While Northern Ireland, Scotland and Wales have devolved responsibility for health care and have not been subject to the same level of reforms and restructuring, they too have seen the benefit of practices working together in federations (Northern Ireland) and clusters (Scotland and Wales), which have been in place for some time.

It is well established that general practice is coping with an increasing workload partly as a result of the ageing population.,, In many areas there are also problems recruiting GPs.,, As these pressures have risen, increasing attention has been focused on how to maintain and further improve the quality of general practice. However, what counts as ‘quality improvement’ is not straightforward.

Quality improvement in general practice

In its guide to quality improvement, the Royal College of General Practitioners (RCGP) defines it as follows:

‘The term “quality improvement” describes a commitment to continuously improving the quality of health care, focusing on the preferences and needs of the people who use services. It encompasses a set of values (which include a commitment to self-reflection, shared learning, the use of theory, partnership working, leadership and an understanding of context); and a set of methods (which include measurement, understanding variation, cyclical change, benchmarking and a set of tools and techniques).’

As the results of our study show, ‘quality improvement’ and ‘improving quality’ are not the same thing. As in the quote above, ‘quality improvement’ implies the use of formal methods or tools, the results of which can be measured. Improving the quality of the services, however, can also encompass more informal efforts to change and improve the way care is delivered. Many practices are improving the delivery of their services and the way their practices work (for example, enabling a repeat prescribing system to run more smoothly) without using formal tools, but the results of these initiatives will not necessarily show up in ways that can be measured, or in standard metrics, such as the Quality and Outcomes Framework (QOF) or other measures of performance. In fact, as our survey findings on barriers and facilitators of QI activity illustrate, reporting and surveillance can potentially obstruct practices’ attempts to improve services.

Traditionally, more attention has been focused on QI in secondary care than primary care. In 2011, a report from The King’s Fund, Improving the quality of care in general practice, recognised that QI was not yet embedded in general practice and the authors were unable to quantify the level of QI that was being conducted at that time. Furthermore, most practices are small businesses owned and run by the GP partners, who have a contractual rather than employer/employee relationship with the NHS, so it is possible that the levers and drivers for change within practices may overlap, but not directly correspond to, those in other, particularly larger NHS organisations, such as acute hospitals.

Nevertheless, recent years have seen increasing focus on developing and supporting QI in general practice. Box 1.1 provides a summary of the key developments.

Box 1: Key developments aimed at promoting and facilitating quality improvement in general practice across the UK since 2010


  • Launch of revalidation for all doctors in 2012, which includes a requirement to engage in quality improvement activity.,
  • Creation of a range of RCGP quality improvement resources, such as a Quality improvement in general practice guide; QI Ready online modules; and a network of QI regional champions.


  • Start of Care Quality Commission (CQC) inspections of GP practices in 2014 with inspection teams charged with examining the extent to which there are systems and processes for learning, continuous improvement and innovation.
  • Publication of the General practice forward view in 2016, which identified the development of quality improvement expertise as one of 10 ‘high impact actions’, which was followed by the launch of the General Practice Development Programme aimed at building the capacity and capability for improvement within the service.
  • Launch of a new quality improvement domain in the 2019/20 QOF alongside the publication by NHS England of An introduction to quality improvement in general practice.


  • Launch of GP Clusters in 2017, with the aim of ‘providing a mechanism whereby GPs may engage in peer-led quality improvement activity within and across practices’.
  • Creation of the Scottish Patient Safety Programme in Primary Care in 2013 with a view to improving safety processes, safety culture and leadership.,
  • Development of improvement resources by NHS Education for Scotland including a quality improvement in primary care guide.


  • Development of a national programme for primary care by 1000 Lives Improvement, which includes a focus on building improvement capacity and capability in primary care through training, support for networking and sharing learning.
  • Creation of a network of primary care quality improvement leads to support the development of Primary Care Clusters across Wales.

Northern Ireland

  • Launch of Health and Social Care Quality Improvement to give health and social care professionals with an interest in improvement and innovation the opportunity to connect and share best practice.

The research study: Exploring how practices improve services

In order to investigate QI activity in general practice and how it can better be supported, we conducted a survey of GPs and practice managers across the UK during the second half of 2017.

Our specific research questions were:

  • What are the current motivating factors for undertaking QI in general practice services?
  • What sorts of QI activities currently take place in general practice?
  • What role do different members of the practice team play in improvement work?
  • What factors, internal or external to general practice, support and encourage QI?
  • What are the internal and external barriers to QI in general practice?
  • Is it possible to identify common levers for change in general practice QI?
  • What support do practices say they need in order to develop QI work?

We sent an email invitation to take part in an online survey to all 46,238 GPs on the Royal College of General Practitioners membership list (as at 24 July 2017); those who had not practised in the UK in the past 12 months were identified and excluded from the survey. Overall, 2,377 responses from GPs were included in the survey dataset. In order to survey practice managers, we contacted all 9,153 practices in the UK and received 1,424 responses from practice managers. The initial design of the survey was informed by 26 semi-structured interviews and one practice-based focus group. Further information on survey methods and quality assurance is provided in Appendix 1.

The percentages of GPs and practice managers who responded to the survey by country are very similar to the percentages of GPs and practices registered with the BMA across the four countries of the UK (Table A.2). For example, 83% of the GPs registered with the BMA are in England, compared with 10% in Scotland, 5% in Wales and 3% in Northern Ireland; by comparison, 81% of the GP responses to our survey were from GPs in England, 12% from Scotland, 5% from Wales and 2% from Northern Ireland. The majority of GPs completing the survey were partners (64%), with just over 20% being salaried GPs and 15% being GP trainees (Table A.1); again, breaking down the responses across the different countries of the UK, the responses were broadly representative of GP type, apart from Wales, where our data under-represents salaried GPs. Further analysis of survey respondents is given in Appendix 2.

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