Against the odds: Driving improvement in primary care

Today the Care Quality Commission published The state of care in general practice, which sets out how the quality of GP practices has changed in England between 2014 and 2017. The good news is that nearly nine out of every ten GP practices are providing ‘good’ or ‘outstanding’ care, and that many GP practices originally rated as ‘requires improvement’ or ‘inadequate’ have improved in this period.

This is encouraging given the huge pressures that primary care services are confronting. GP workloads are growing and becoming more complex. Funding has not kept pace with rising demand. The primary care workforce needed to meet these added challenges is increasingly in short supply. The BMA recently warned that more than eight out of ten GPs describe their work as ‘unmanageable’, which is perhaps why GPs in the UK reported having the highest levels of stress compared to ten similar countries. And though the CQC report highlights important progress, it also raised concerns about how safety is managed and promoted in about 15 percent of surgeries.   

How to make sense of this mixed picture? One thing the CQC report makes clear is that even against enormous pressure, change can happen. This is something the Health Foundation has seen in the work we support, where we witness inspiring examples of general practice driving improvement against difficult odds.

Take Buxted Medical Centre in East Sussex. Part of our Innovating for Improvement programme, the team worked with local partners to pilot a new pathway to provide more coordinated and responsive dementia care in general practice and the community. The model involved a multidisciplinary team who provided a package of care based on each patient’s needs and preferences. Volunteer dementia ‘guides’ provided support throughout the care journey, and a GP-led weekly clinic coordinated rapid interventions for people at risk of deterioration. The results from this project are encouraging, and suggest the model helped patients feel more supported and less socially isolated. The local CCG is now working to scale up the intervention across the STP.  

Another example comes from Cowgill Surgery in Bradford, which worked to improve early investigation and diagnosis of upper gastrointestinal cancers. Referrals can be delayed if a patient must wait for a physical examination with a GP, which typically isn’t required to make an informed decision about referral for this type of cancer. This project implemented a pathway whereby patients can bypass an initial GP appointment by using a questionnaire that captures information about the patient’s symptoms and history. Using an algorithm, patients are triaged to the most appropriate pathway, and the GP practice notified of the results. Health Foundation funding supported this project, and it has since become a standard part of care across participating practices. Early results suggest the intervention has helped the practice meet the NICE recommended standard of offering a referral to endoscopy in two weeks .

In both projects, success didn’t come easily. Teams noted the challenges of driving improvement in primary care, when GPs already have so many constraints on their time and capacity to test something new. In the case of Buxted, the team spent months knocking on doors and engaging with GPs and other local partners directly, ensuring they designed a pathway which met local challenges and responded to the different needs of stakeholders. In Cowgill, GP workload proved a significant barrier to their engagement in the intervention, but dedicating practice ‘champions’ and training sessions helped.

The challenge lies in making improvements like this the norm rather than the exception, which is why supporting improvement in primary care remains an important focus for the Health Foundation. We have recently funded a set of innovation projects in primary care as part of our Innovating for Improvement programme. Meanwhile, we are supporting a London School of Hygiene and Tropical Medicine study examining how general practice managers can be supported to lead improvement, as well as in-house research on how GPs are using data to drive system change. We’ve also funded the Royal College of General Practitioners to develop QI tools to support GPs and practice staff.

So while The state of care in general practice report contained grounds for optimism, the work isn’t over yet.

Sarah Reed (@sjanereed) is an Improvement Fellow for the Health Foundation