Too much and not enough Quality improvement in general practice

Recent media reports have drawn further attention to the number of patients waiting over 3 weeks for an appointment, highlighting, once again, the heavy workload pressures facing GPs and practice teams. According to the Royal College of General Practitioners (RCGP), general practice is now ‘running on empty’ –  urgent action is needed simply to make the job of a front-line GP ‘do-able’.

Naturally, much of the ensuing debate has focused on how to recruit and retain enough GPs and other staff to help practices get to grips with patient demand and avoid burnout. This is vital. However, it’s important not to lose sight of other challenges, such as ensuring practices have the skills and support to help them improve the quality of their services. This is especially so now that quality improvement modules feature in the Quality and Outcomes Framework in England.

That said, we still know very little about the level of quality improvement awareness, knowledge and usage within practices. Quality improvement seems to have a far higher profile in general practice than it did a decade ago – certainly if the number of Health Foundation funded improvement projects in the sector is anything to go by – but data to confirm this are in short supply.

To help close this gap, the Health Foundation has funded research by the London School of Hygiene & Tropical Medicine (LSHTM). The team’s final report, which we recently published, draws on survey responses from over 2,300 GPs and over 1,400 practice managers across the UK, along with interviews and other qualitative research. It gives us a unique insight into the state of quality improvement in general practice, and a better understanding of how to help the sector strengthen its improvement capability.

The research found that most GPs and practice managers see improving quality as a core aspect of their work. Almost all of them (99%) reported their practices being involved in some form of improvement activity, with the driver for much of this work coming from within practices rather than external prompts. Further, many respondents (60% of GPs and 71% of practice managers) said they were working collaboratively with neighbouring practices to improve services.

But the LSHTM team also identified 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 requirements), and the time implications of these, were sources 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 improvement in secondary care – also emerged as a major challenge for almost 80% of GPs.

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.

The good news is that there is now a growing range of dedicated resources and networks to support quality improvement in general practice. The RCGP has set up QI Ready, an online learning and networking platform, while the Q community has a special interest group focused on primary care. But, as the LSHTM’s research highlights, it’s crucial that the provision of such resources is accompanied by steps that make the time for practices to learn about, plan and participate in improvement. Without such headroom it will be very hard for practices to create an environment that is conducive to improvement. However, for this to happen, practices will need the concerted and sustained support of all partners at local, regional and national level.

Bryan Jones is Improvement Fellow at the Health Foundation