How do you build a system that continually improves in primary care?

Deborah McBeal is Deputy Chief Officer at NHS Enfield Clinical Commissioning Group (CCG), and a Health Foundation Leadership Fellow. We spoke to her about improving quality in primary care in England and how CCGs should be supporting GP practices to develop their capacity for continual improvement.

What are the specific challenges and opportunities around making sure a primary care organisation is ready for improvement?

When it comes to assessing any organisation’s ability to change and improve, it’s the people behind the projects who will make a difference. That’s the same whatever part of the health sector you work in.

The number of people working in primary care who have specific training or skills in quality improvement is pretty low. General practices tend to be fairly small organisations, so you don’t get the same level of skills mix that you get in a hospital. A hospital is far more likely to have improvement skills and capabilities within the organisation, just due to the sheer number of people working there, plus they’ll probably be employing people specifically to lead change projects or drive work in quality, patient safety etc.

But on a more positive note, in some ways it’s easier for primary care organisations to make improvements because they’re so small. General practices are independent organisations with a fairly flat structure, so they don’t have the myriad of governance processes to go through. You can have a conversation about what needs to change, and then actually start testing ideas for improvement straight away. It’s much easier to be in control and to have an impact quickly.

Do CCGs have a role to play in bringing primary care providers together to assess and improve their readiness for change?

Yes, the quality improvement agenda definitely sits within the CCGs and we have a big role to play here. We bring practices together in localities and encourage them to challenge each other and share learning about how to improve outcomes for patients. So at a recent locality meeting, we (the CCG and other practices within the locality) heard practical examples of how an Enfield GP practice manages blood pressure monitoring for patients with coronary heart disease and how they are now ranked in the top 1% nationally for this indicator. We provide as much support and influence as possible to support improvement across different organisations.

Because of the way primary care is structured, with lots of small organisations, there’s a level of competitiveness between practices and this really helps with improvement. We’ve found it works to encourage ideas to be rolled out in a planned way across the organisations that seem more willing to embrace change. Some practices are keen to be the front runners, chomping at the bit to do something. If the ideas work they become champions who then convince their other colleagues. When you see variation in outcomes between the practices it speaks for itself.

What incentives are CCGs able to give to support improvement in primary care?

If something falls within the core contract between the GP practice and NHS England then it's a case of encouraging additional work to be done to make improvements. If it falls outside of the core contract then CCGs can develop improvement schemes that reward practices for working towards and making improvements.

The focus might be on the benefit to patients, but there are often wider incentives for providers to make changes such as freeing up time and resources, creating economies of scale, or making processes more streamlined. For example Enfield has variations in referral rates to secondary care, and the CCG is supporting practices to free up time to carry out clinical audits and clinically challenge their referrals and then share their findings with other practices within their locality as a way of sharing learning and supporting improvements.

There’s not a one size fits all approach in primary care though. Every practice has a different way of doing things, so it’s about being agile enough to work with different organisations in different ways.

What kind of central support is there to enable quality improvement in primary care?

There’s very little really. There might be a few avenues for securing funding at practice level, but really it’s a voluntary part of service delivery for GP practices. The quality outcomes framework does incentivise and reward better outcomes, and that provides a level of standardisation. But there’s really not much in the way of the softer support needed for people and organisations to improve their skills, for example training in quality improvement methods. It would be great if there was more. It will be interesting to see whether there’s any focus on this by any of the NHS organisations that support quality improvement. 

Why is it so important for primary care organisations to be able to improve their capacity and capability for improvement?

For me, primary care is the lynchpin. It underpins all of the health care system and is the point at which patients access the NHS (and lots of social care as well). There’s so much potential for us to do more and make improvements that really improve outcomes for patients. If people have really good access to primary care and they get treated quickly and well then they won’t need to go into secondary care. So I think there’s a real opportunity to share improvement goals with secondary care. 

Historically the majority of funding has gone into secondary care, even though the majority of activity happens in primary care. NHS England has just announced a multi-billion pound General Practice Forward View initiative, which will ensure more support for primary care. This is great as primary care has been a completely untapped and under resourced part of the system in terms of improvement.

There’s also lots of opportunity for practices to work together more, through federations and networks. They could be sharing support services functions and pooling their knowledge and expertise. There’s lots of work going on in this area.