Quality improvement in general practice: what do GPs and practice managers think? Results from a nationally representative survey of UK GPs and practice managers

Introduction

This paper presents the results of research conducted in 2017, exploring service improvement activities being undertaken in general practices across the UK and the factors that facilitate or obstruct that work. The research was prompted by growing interest in general practice across the UK by the Government and other national bodies, specifically, how to improve the quality of general practice services.1–5 In 2019, this culminated in the inclusion of a new quality improvement domain in the revised Quality and Outcomes Framework (QOF) in the English National Health Service (NHS) general practice contract,6 following a review of the QOF scheme by NHS England.7 Initially, the new domain was focused on improving both end of life care and prescribing safety. Subsequent inclusions focused on helping people with disabilities and early diagnosis of cancer. The new domain is the latest expression of an increasing focus on general practice across the UK. In England, it follows the inclusion of general practice in Care Quality Commission (CQC) quality inspections8 9 and publication of the General Practice Forward View,10 both of which have detailed ways that general practice can be better supported and improved.

There have been earlier attempts to improve quality, for example: the introduction of targets for cervical cytology and childhood immunisations introduced in the 1990s. However, in 2011, a King’s Fund report, ‘Improving the Quality of Care in General Practice’, stated that quality improvement was not yet embedded in general practice and it was unable to quantify the amount of quality improvement that was being conducted at that time.11 In Northern Ireland, Scotland and Wales, where responsibility for the NHS is devolved, there has not been the same level of regulatory and reimbursement reform, but general practice quality has also become a policy priority.12–14

While Ferlie et al15 comment that ‘service improvement work has developed as an important organisational and managerial activity within the English healthcare sector over the past 20 years or so’, in line with other countries and healthcare systems, much of the activity and research about organisational (as opposed to specifically clinical) improvement has been in secondary, rather than primary, care.16–18 This is despite the fact that general practices deliver 90% of patient contacts in the NHS and remain the key gatekeeper to other services. Now that a new quality improvement domain has been introduced into the QOF (although only in England), it is timely to describe the nature and extent of improvement work in general practice, as well as to explore how best to support the extension of quality improvement work in general practice.

This paper presents the results of the first UK-wide survey of general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being undertaken in practices, and the factors that facilitate or obstruct that work. The analysis focuses on comparing GP and PM involvement in and experience of quality improvement activities rather than differences in quality improvement activity between different types of practice (eg, by patient list size, location, etc). More information on the latter is given elsewhere.19 It was important to include PMs in the study because managers are known to be highly influential in team cohesion and development, but their views are seldom sought.1 They are also the members of the practice team who mediate the introduction of ‘increasingly complex service regulations’,20 and are key to understanding the organisational processes and dynamics related to improving quality. Finally, they are likely, through management training, to be aware of both improvement and change management techniques.

However, what counts as ‘quality improvement’ is not straightforward to define. ‘Quality improvement’ and ‘improving quality’ are not the same thing. In its guide, ‘Quality Improvement for General Practice’, the RCGP defines quality improvement as:

“…. a commitment to continuously improving the quality of healthcare, focusing on the preferences and needs of the people who use services. It encompasses a set of values (which include a commitment to self-reflection, shared learning, the use of theory, partnership working, leadership and an understanding of context); and a set of methods (which include measurement, understanding variation, cyclical change, benchmarking and a set of tools and techniques).5”

While this implies the use of formal methods or tools, the results of which can be measured, the wider activity of improving the quality of services encompasses more informal efforts to change and improve the way processes in the practice are undertaken. The CQC acknowledges the difference, drawing ‘a distinction between efforts focussed on “improving quality”, and “quality improvement” which involves the “use of a systematic method”’.8 Many practices are likely to be improving the delivery of their services and the way their practices work without necessarily using formal tools.21 For clarity, in the survey, when we were referring to informal activities we used the terms ‘improving quality’ or ‘improving patient care or services’ and ‘quality improvement’ when we were referring to activities which used formal improvement tools.

Methods

To inform the design of the surveys, 26 semistructured interviews and one practice-based focus group were conducted February to May 2017. The interviews were with a range of GPs and PMs from across the UK, as well as interviewees working at national-level agencies concerned with quality in general practice, for example, NHS Improvement. The GPs and PMs were all working in general practice, but some also worked part time at a national policy level. The focus group was a team of doctors within one English practice. The interviews and focus group enabled us to explore what GPs and PMs think about improving the quality of services, how they would define quality and whether it is an activity that is built into their day-to-day activities. They provided a picture of some of the problems practices are facing and how practice teams manage them. We used this information to design the survey questions to enable respondents to relate these to their own practices and ensure that we used appropriate terminology. We also wanted to design questions that would avoid a defensive reaction or appear to be judging practices. The questionnaire underwent cognitive testing on a small number of GP and PM respondents. This included respondents in different countries of the UK, but we were not able to test it on GPs and PMs in all four. Some questions were subsequently amended to improve their clarity.

Two survey questionnaires were designed, one for GPs, one for PMs, containing identical questions about the types of activities practices were undertaking to improve patient care or services in the 12 months preceding the survey and what motivated practices to undertake these activities (a copy of the GP questionnaire, showing the quality improvement questions, Qus 8–34, shared with the PM questionnaire is available at the end of this paper online supplemental file 1). We were interested in the factors perceived to be helpful in supporting practices to undertake improvement activities, as well as the barriers perceived to make it more difficult. The survey included a set of questions about whether respondents had used, and received training in, different tools or other training designed to help them improve patient care and services. Finally, we collected data on the characteristics of respondents and their practices, including the amount of protected time available to improve patient care and services, number of GPs and partners, different types of staff, contract type, list size, and so on.

When considering the facilitators and barriers, respondents were asked to rate a series of options on a 5-point Likert scale from ‘very helpful’ to ‘not very helpful’ in the case of facilitators and ‘no more difficult’ to ‘much more difficult’ in the case of barriers. We asked about the amount of protected time to improve patient care and services that respondents had, using a sliding scale, set at zero, which the respondents could move to the corresponding number of hours available per month.

An email invitation to take part in an online survey was sent to all 46 238 GPs on the RCGP membership list (as at 24 July 2017). Thus, the survey invitation was sent to all member GPs in a practice. The list included a small number of GPs who had retired, or, for various reasons, were not currently practising. These were identified at the beginning of the questionnaire and GPs who had not practised in the UK in the past 12 months were excluded from the survey.

There is no database of PMs; therefore, in order to survey PMs, we sent an invitation letter to all 9153 practices in the UK, addressed to ‘The Practice Manager’. Some managers may prefer a different title, but we felt that this was generic enough to be generally recognised. Although we are aware that some larger practices may have more than one PM, the survey allowed only one response per practice. Both surveys were launched at the end of July 2017 and closed at the end of September 2017. An initial invitation and two reminders were sent, each containing a link to the survey. More detail on the methods used can be found in Gosling et al.19

The data from the GP and PM surveys were summarised separately using descriptive statistics. In the GP survey, since it was possible for more than one GP from a practice to respond to the survey, results that refer to the practice level (rather than individual GPs) would over-represent practices if there was more than one respondent. Therefore, when presenting results at the practice level, the data have been weighted by practice list size (using number of registered patients at a practice), so that the survey distribution of practice list size matches that of the practice population in the UK. The number of responses varied by question as not all participants answered all questions. In addition, we excluded responses for ‘don’t know’ and ‘not applicable’. For the questions that asked respondents to rate responses on a five-point Likert scale, we created a dichotomous outcome (‘very helpful’ and ‘fairly helpful’ vs ‘not helpful’, and ‘much more difficult’ and ‘somewhat more difficult’ vs ‘no more difficult’). When reporting by GP type (eg, partner or salaried GP) or country, these categories were collapsed into ‘helpful’ or ‘difficult’. Below we outline the main findings from both surveys.

Results

Overall, 2377 GPs (1511 GP partners, 509 salaried GPs and 357 trainee GPs) from 1946 practices were included in the analysis. We do not know the exact number of ineligible GPs on the RCGP membership list, but we estimate the response rate to be between 7% and 10%. Table 1 provides the distribution of respondents by country, compared with British Medical Association data for GPs at the time the survey was undertaken and shows that the respondents were broadly representative of all GPs. Overall, 1424 PMs were included in the final dataset, which gives a 16% response rate based on the number of practices (rather than PMs, as the total number of PMs is not known). Further details on the achieved samples of GPs and PMs can be found in Gosling et al.19

Discussion

The findings show that nearly every practice that responded to the survey was planning and/or had undertaken activities to improve patient care or services in the last year. To the extent that the survey is representative of practices, improvement work appeared to be mostly self-driven and motivated by prompts from within the practice, rather than external bodies. However, practices indicated significant barriers to improvement work, with ‘high levels of patient demand’ and ‘too many demands from external stakeholders’ being reported as a barrier by nearly all GPs. A similar picture was presented by the PMs. It is noteworthy that only 42% of GPs and 38% of PMs thought that ‘financial support from external organisations’ would be helpful. Financial support often comes with onerous application and reporting requirements, and this conclusion was borne out by the report of the Department of Health & Social Care’s General Practice Partnership Review,24 which stated:

“There are too many small sums of money, with an overly complex bidding process, and funding is all too often non-recurrent.”

At the time, not many GPs and PMs were using formal quality improvement tools, aside from audit and significant event audit. However, the use of the phrase ‘continuous quality improvement’, a term from ‘lean management’, within the QOF indicator in England, implies an expectation that formal tools be used.25 26 Training will need to be made available to enable this and our data indicate that there is an interest in and willingness to be trained in quality improvement tools. The RCGP currently has two resources available: its ‘Quality Improvement Guide for General Practice’5 ; and an on-line resource, ‘QI Ready’.27 For this to be practical, protected time for both improvement work and training needs to be made available.

Unlike consultants in secondary care, there is no facility for protected time for training or service improvement in the GP contract. Indeed, the lack of protected time has been an issue for many years.28 Our research shows that very few GPs are able to access protected time, for example, in order to get the whole team together, whether to plan and undertake specific improvement activities or just to discuss the day-to-day operation of the practice.

The Scottish NHS has recognised the importance of protected time and in the latest Scottish NHS General Medical Services contract (2018) states that “from April 2018, each practice will receive resources to support one session per month for Professional Time Activities. There is a clear intention to achieve, over time, regular protected time for every GP” to be used for “assessing and developing services intended to meet the needs of their patients and local communities”29 There is no mention of protected time in “Investment and Evolution”, the equivalent framework for contract changes to deliver the NHS Long Term Plan in England.25

Conclusion

It is clear from these findings that GPs and PMs are interested in improving the quality of their services and that practice teams are undertaking improvement activity as a routine part of their work. This means that the new quality improvement QOF domain is likely to be relatively easily accepted by GPs in England, particularly as practices are already undertaking improvement projects on prescribing, end of life care and collaboration with other practices—the specific indicators and criteria of the new domain. However, for improvement work to become routine for practices, it will be important for the NHS in the four UK countries to work with practices to mitigate some of the barriers that they face, in particular, the lack of protected time for practice teams to meet to identify areas for improvement, plan that improvement and acquire training in the tools that might assist them.