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Rise to the challenge

27 June 2011

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Independent Consultant in Practice Management

Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on
both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract

The King’s Fund’s report into the quality of care in general practice does not make entirely comfortable reading.(1) It challenges those of us involved in practice service delivery to move away from any feeling of complacency and re-examine how we do things.

While the think tank’s independent inquiry examined the quality of English general practice, its findings are nonetheless relevant throughout the whole of the UK. Chris Ham, King’s Fund Chief Executive, describes the report as “a gauntlet thrown down” in challenging general practice to do better and prove that it is doing so.

While much of the report specifically concerns the direct care provision delivered personally by GPs, a good deal of it examines the organisational elements of general practice in which practice managers play a significant part. It concludes that while the majority of care provided is good, there are significant variations in performance and gaps in quality provision – and therefore considerable room for improvement.

Sir Ian Kennedy, Chair of the inquiry’s independent panel, said: “General practice is not an area of healthcare greatly given to self-reflection and self-challenge.” This rather disappointing statement suggests a high level of complacency, and the suggestion throughout the report is that general practice will need to step up to the plate much more from this moment on.
So, what particular areas should practice managers look at in order to make a difference?

Teams and skill mix
The introduction of GP consortia is likely to take general practice a further step away from single-handed practitioners. Sir Ian Kennedy comments that healthcare will increasingly be delivered by teams, including patients as active participants in decisions. These teams will need to evolve a skill mix to include a wider range of professionals, with the GP as an expert adviser.

The report goes on to say that commissioning practices in England will need new skills and to engage more with local authorities and other public services in order to deliver care in the newly emerging models.

As we have seen in recent years at grassroots level, the report also identifies a significant increase in practice nursing staffing levels and a 10-fold increase in salaried GPs from 1999 to 2009. In the future, practices are likely to find that delivery of care models will move even more towards a team approach, with a mix of salaried GPs and nurses seeing patients for unscheduled care and GPs taking a role involved more with both commissioning itself and with delivering care to patients with complex and long-term needs.

Working in a consortium will inevitably throw up issues about the quality of care delivered by different practices. The King’s Fund report suggests that high-performance, well-developed practices should be prepared to support ‘weaker’ practices and that mechanisms should be developed to help these practices take over struggling practices if extra support and investment are not delivering the required quality improvements.

In order to be successful commissioners and to deliver good-quality care to an ageing population, practices must consider looking again at skill-mix, along with identifying training needs. Practice managers are ideally placed to lead the practice through this process. They are very likely to be in key positions when interacting and planning with other service providers and so should ensure they have the knowledge and skills needed for these activities.

Quality data and  IT
The King’s Fund report identifies that practices require much more quality and accurate data to be able to continue to focus more on improving the quality of care. Standards should be set for the quality of data recording and also for the completeness of data recording.

Across the UK, various attempts have been made to improve consistency of data recording, but this is still patchy. Practices remain unaware of the differences between themselves and other, similar, practices. They should be given opportunities to be aware of these variations and to take action; this cannot happen without accurate comparative data being available in the first place, which has been consistently recorded to a set standard.

Consortia will be required to take a population-based approach to care and to be proactive in preventing ill health. The report recommends that this will require more data availability and that data will have to be available according to consortium boundaries. The Department of Health (DH) and the NHS Information Centre will have a role to play here, but practice managers are in a strong position to influence how data is gathered locally.

The report also states that general practice has been slow to adopt IT innovations to help patients interact with the practice. Interactive websites are used by a lot of practices, but many practices are extremely under-developed in this area. Patients expect to access all services online, and general practice is not seen as being any different.

Practice managers should look critically at data collection consistency and accuracy in their own practices. They should make themselves aware of initiatives to improve these areas. Managers should now start to identify data needs across their consortium and consider how this could be collected. They should also look critically at how patients use IT to interface with the practice to access services.

Access and continuity
Although, according to the report, most patients report good access to their practice most of the time, there are still wide variations. A series of Royal College of GP/DH workshops run a year ago throughout England on “Access and Responsiveness” showed that, across the country, there are pockets of excellent activity in relation to access, but in the main practices still struggle to find and apply tools to improve access.

In addition, the King’s Fund report recognises that some access initiatives in the last few years have had a detrimental effect on continuity of care. This is a cornerstone of general practice and we ignore it at our peril. The needs of an ageing population with chronic diseases and complex, long-term needs will not be best met by a service where continuity of care is devalued.

The report says: “General practice needs to reach out to all those in their local community who need care but who are not currently receiving care”. Clearly, this is very much the gauntlet being thrown down!

Practice managers should keep access issues near the top of their list of areas for regular review. Do not assume that your current access arrangements will always work. Look for hints, tips and tools on websites that specialise in practice management. In Scotland, look at the “Treating Access” toolkit on the RCGP Scotland website. Keep reviewing continuity of care and consider ways to measure it (see below).

The report states that general practice “is not greatly given to self-reflection”. For many, this may be disappointing to hear. However, a lot of practice managers and GPs struggle with significant event audit and the application of an audit cycle with criteria and standards set.

The report suggests that practices should undertake more qualitative assessment, as well as quantitative, and should consider the uses of audit, peer review and qualitative research methods. Additionally, it says that practices should undergo more external scrutiny, as well as internal scrutiny, and that the results of these processes should be transparent so that both users and regulators can see the quality of care offered.

Practice managers should ensure that they are competent in the use of tools such as significant event audit and the clinical audit cycle. They should at least be familiar with the difference between qualitative and quantitative data, and know when to use each. Useful areas to start considering might be continuity, access, referrals 
and prescribing.

Patient involvement
Not surprisingly, the inquiry report says that patient expectations of service delivery have changed and that patients would like greater opportunities to take an active role in decision-making. This applies both specifically in the consulting room and, more generally, in terms of how the practice delivers care.

The practice manager is key to promoting, introducing, developing and sustaining patient involvement and engagement. Do not assume that you have tried everything and that it will not be a success. Look for innovative approaches and take manageable steps.

This is a summary of some very significant recommendations contained in the King’s Fund report. It is strongly recommended that you take the time to read it in full (see Reference below) and avoid the temptation to assume that everything in the garden – ie, your own practice – is rosy! ■

1. The King’s Fund. Improving the Quality of Care in General Practice. Report of an independent inquiry commissioned by The King’s Fund. London: The King’s Fund; 2011. Available from: