A survey of thousands of GPs and practice managers in the UK has found nearly all are undertaking some sort of quality improvement, but few have the resources, skills or “protected time” for these activities.
External support, financial or otherwise, does not help much if it comes at the cost of more bureaucracy – worth noting as Australian general practices gear up for the QI Practice Incentive Payment scheme.
And when you get down to the brass tacks of QI, root cause analysis and run charts don’t appear to set many clinicians’ hearts a-flutter.
The London School of Hygiene and Tropical Medicine asked individual GPs and practice managers to complete an online survey including questions about QI activities, motivations, roles played by practice staff, what barriers exist and what support is needed. About 2300 GPs and 1400 managers responded.
Only 16 GPs and six practice managers said they were doing nothing to improve quality, but even these low numbers are surprising.
British GPs have to engage in QI as part of their revalidation – the extreme form of continuing professional development under which doctors must demonstrate their fitness to retain their licences.
QI is also now part of the Quality and Outcomes Framework, an incentive program for GPs under the NHS General Medical Services contract.
According to the survey, the top areas in which QI had been undertaken included prescribing safety and end-of-life care, two focal areas in the 2019-20 QOF. Others were access, chronic disease management, collaborating with other practices and health promotion.
Two-thirds of GP partners (as opposed to salaried GPs) said they lacked the resources to undertake QI.
Ability to work as a team, good clinical leadership, quality-assessment skills and improvement training were the top “facilitators” of QI, followed by protected time – hours that under the practitioner’s contract cannot be used for clinical duties. Four out of five GPs said protected time would help them carry out QI.
Interestingly, financial and other support from external organisations were ranked quite low, apparently reflecting the added bureaucracy and paperwork that is the price of such support.
Heavy patient workload and staff shortages were, predictably, two highly rated barriers to doing QI.
“Too many demands by NHS agencies” was another, with practice managers complaining about “frustrating and time-consuming” reporting requirements that added to their workload and often created duplication.
Lack of data, skills and engagement by clinical and non-clinical staff were also barriers.
The results suggest a level of mystery remains around the QI methods that practices are expected to use. When asked which of a list of such tools they had used, only audits received above 90% from GPs and managers.
For more obscure instruments, like PDSA (Plan, Do, Study, Act) cycles, root cause analysis, change management, process mapping and run charts, the numbers were in the low double or single digits. Even fewer had trained in these arts.
In a commentary on the report arguing for more investment, co-author Bryan Jones from The Health Foundation says formal QI is useful “at a time when GP practices are struggling to recruit and retain GPs and other staff in the face of growing demand and constrained resources”.
Its “structured approach to tackling complex problems” can help drive up efficiency and foster useful collaboration between practices, he writes.
“It offers practices the chance to free up capacity and time by tackling constraints, delays, duplication and other problems in their care processes and pathways. It allows them to take a step back and look with fresh eyes at the service they provide, and the tools they need to do things differently.
“And because QI works best when it is a team enterprise, it can help to capitalise on the talents and energy of the whole practice team and, in doing so, improve morale and confidence. Moreover, it gives patients the opportunity to get involved in shaping and testing the services they use.”