Responsibilities, activities and motivations to improve quality

Views of the current quality of care

Before asking GPs and practice managers about specific improvement activities, we wanted to gauge their perception of the need or desire for change in their practice. We asked: ‘How would you rate the quality of care and services your practice provides today, compared with what you think it should be?’ Half of GPs and practice managers felt that their expectations of the quality of their practice’s care and services were being met, with another 23% of GPs and 35% of practice managers saying that the quality of care was above their expectations (Table 2.1). This means that more than one in four GPs felt that the quality of care in their practice was below their expectations.

Table 2.1: GPs’ and practice managers’ assessment of the quality of care provided in their own practicei (%)

GP partners

Salaried GPs

Trainee GPs

All GPs

Practice managers

Well above expectations






Above expectations






Meets expectations






Below expectations






Well below expectations






Base number






i Unless specified, the tables report data from both GP and practice manager surveys.

Responsibility for improvement

When asked who in the practice was responsible for quality improvement (QI), the majority of respondents, both GPs (62%) and practice managers (52%), reported ‘no single person’ and that responsibility varied according to the improvement activity. We also asked GPs and practice managers to rate the level of involvement of different types of practice staff in improvement work (‘very involved’, ‘somewhat involved’, ‘not very involved’ and ‘not involved’). Both GPs and practice managers reported that the majority of staff (including nurses and other clinical and administrative staff) were involved in improvement activities, although we were not able to ascertain how this involvement manifested itself. GP partners and practice managers were found to be the most involved in improvement work, followed by practice nurses, administrative staff, other clinical staff and only then salaried GPs. This suggests that there may be an issue with how salaried GPs are being integrated into practice teams, but this would require further exploration.

The importance of practice managers’ contribution to the improvement work of practices was highlighted in another question in the GPs’ survey. When asked about practice improvement activities, 75% of GPs agreed with the statement that ‘Our practice manager plays an important role in setting priorities for improving the services we provide’ (although the figure was slightly higher in England than in the other UK countries). GP partners agreed with this statement more than salaried GPs (53% and 41%, respectively). This may be because partners and practice managers typically form the management team of the practice and are more likely to be working together to determine priorities for the practice. The value of an effective working relationship between GPs and the practice manager has been highlighted by the CQC in its 2017 report The state of care in general practice 2014 to 2017: the CQC identified that practices scoring higher ratings were those with a practice manager, and where the GPs and practice manager worked together.

Improvement activities

Now that QI domains have been included in the QOF in England, it is even more important to understand how practices engage with and undertake improvement activity and integrate it into their day-to-day work. Our data indicate that improvement activity is common and an ongoing process for the vast majority of practices, with a wide range of work being undertaken, irrespective of impending CQC inspections or other external demands. Only 16 GPs and six practice managers in our survey indicated that their practices were not undertaking any activities to improve care. The six most common areas where practices were working to improve services are detailed in Table 2.2 (the sixth most common was different for GPs and practice managers).

Table 2.2: Areas in which improvement projects have been undertaken, by GP type and practice managers (%)

Area of activityi

GP Partners

Salaried GPs

Trainee GPs

All GPs

Practice managers













Chronic disease management






Collaborating with other practices






End-of-life care






Health promotion






i Respondents were asked to tick as many as were applicable from a list.

Although there are some differences between the percentages of GPs and practice managers who have indicated improvement work in these areas, it is clear that prescribing, access, chronic disease management and collaborations have been uppermost in the minds of GPs and practice managers, well above other concerns. It is also important to note that the two new QI domains in the 2019/20 QOF – prescribing and end-of-life care – feature in the top five. ‘Collaborating with other practices’ also features strongly, with 60% of GPs and 71% of practice managers selecting this as an area of improvement work – in advance of the announcement of the new PCNs in the NHS long term plan.

Prompts to improve

Our survey found that most improvement activity was generated from within practices, rather than being externally driven. It is perhaps surprising that, in England, preparation for CQC inspections did not seem to prompt specific improvement work, even though the inspection report itself will have subsequently indicated priority areas for improvement.

When asked where the prompts came from to initiate an improvement activity, Significant Event Audits were the most common for both GPs and practice managers (slightly more for GPs (62%) than for practice managers (55%)), followed by discussion at practice meetings (58% for both practice managers and GPs) and then patient complaints (more for practice managers at 48% than for GPs at 36%). Prompts from external organisations, such as from the Clinical Commissioning Group (CCG), Health Board, or NHS Trust were rated much lower, but featured more for GPs (34%) than for practice managers (20%).

There is undoubtedly a complex relationship between the different options presented in the survey. For example, patient complaints tend to be formal and can potentially lead to a Significant Event Audit, whereas a comment or suggestion by a patient to a receptionist, nurse or GP may follow a more informal route either to the practice manager or to colleagues and then perhaps arrive on the agenda for discussion at a practice meeting. As one of the practice managers we interviewed explained:

‘… patient feedback is a big thing. So we’ve just changed something recently due to a meeting with the patients. And anything really that the staff, especially the staff at reception, and the doctors [who are seeing the practice] day in, day out, so they […] see how it works. So actually I meet weekly with them as well, and I think it’s really important to get their feedback, and then work with them on the change.’

Thus when 58% of GPs and practice managers stated that the source of an improvement activity was ‘discussion at practice meetings’, the area in question may have taken different routes to get to that point.

In order to gauge how the team worked together, we asked the GPs and practice managers about practice meetings – whether and how often the whole team met together. There was little variation between GPs and practice managers, with nine in ten saying that their practice held regular team meetings. These were most commonly held once a month (GPs 31%; practice managers 40%) or, from slightly fewer respondents, once a week (GPs 25%; practice managers 23%). The frequency of team meetings did not vary, irrespective of list size, country, contract type or depending on whether they were separate practices or part of a federation or larger practice grouping.

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