Improving Quality in General Practice many miles to go

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Improving Quality in General Practice -many
miles to go

• Lewis Ritchie

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Conference theme -

• Meeting the Challenge

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Improving Quality

• Putting quality on the map key principles
• Quality development early UK Quality and
  Outcomes Framework (QOF) experience
• Quality improvement - whats needed and whats
  next?

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Quality principle 1

• Clarity of our roles and responsibilities

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the occasion when in the intimacy of the
consulting room or sick room, a person who is
ill, or believes himself to be ill, seeks the
advice of a doctor, whom he trusts. This is a
consultation and all else in the practice of
medicine derives from it.

• Sir James Spence

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The constancy of change.. General practice
has undergone remarkable and relentless change in
the last 20 years and is now being delivered in
different ways, in new settings and by a growing
band of health professionals
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Patient centred care

• Explores the disease and the effects of the
  illness on the patient
• Understands the whole person, the social context
  and the impact that illness will have on them
• Finds common ground in managing the problem
• Agrees goals for treatment

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Patient centred care

• Incorporates health promotion and disease
  prevention
• Maintains and enhances relationships through
  openness and honesty
• Is realistic in the use of time and resources
• Values the principle of equity

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Our roleRejoicing in our generalism
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Tensionspreserving nurturing our
generalism. while adding specialism(s)
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Tensions.community health role v caring for
sick individuals

• General practice beyond the numbers game

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Tensions.Developing an equitable national
health service while maintaining a safe and
effective sickness service
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Tensions.Defining and supporting the roles of
individual health professionals eg the future
GP while promoting effective teamwork
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What Sort of Doctor?
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Quality principle 2

• Agreeing perspectives

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Agreeing perspectives

• Lay/public/patient
• Professional/medical
• Managerial/administrative
• Political

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Mission impossible?

• Difficult? - yes
• Impossible? no
• Timescale? realistic
• Patience, persistence striking of balances

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Quality principle 3

• Measuring things that matter

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Tension whats (readily) measurable may not
(always) be (that) important
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Quality principle 4

• Agreeing quality criteria

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Tensions between evidence base, differing
interpretations and priorities

• Professional ownership essential
• Role of Reference Group
• Evolving process

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Quality principle 5

• Agreeing priorities and resources

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RNZCGP Position

• Health of all will be improved through high
  quality general practice care
• Adequate workforce resources are required (GP,
  nursing management)
• Practice accreditation required and must be
  resourced
• Infrastructure, including IT systems must be
  robust

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RNZCGP High quality based on

• Focus on continuous quality improvement (CQI) not
  just QA
• Quality frameworks to encompass patient centred
  care
• Teamwork focus essential
• Closer non-competitive liaisons with others
• Key cultural mix and groups to be engaged
  including the unique place of Maori
  cultural competence

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Quality principle 6

• Clinical governance a continuous process
• Transparency and accountability imperative

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Quality Principles - Summary

• Roles and responsibilities
• Different perspectives
• Measuring things that matter
• Agreeing evidence-based criteria
• Establishing priorities and resources
• Ensuring adequate clinical governance and
  accountability

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Quality development Early UK Quality and
Outcomes Framework (QOF) Experience
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UK QOF Early experience

• Care improving rapidly pre-contract (BP control
  improved from 72 between 1998 and 2003) -
• ? Increased audit IT infrastructure massive
  increase in practice nurses (gt10 fold increase
  1980 2003)
• Campbell S et al, BMJ 20053311121-23

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UK QOF Early experience

• Post QOF introduction quality of care shows
  further improvement for asthma and diabetes
  care improving rapidly
• For CHD, where care already showing major
  change, improvement has continued at the same
  rate and should have important impacts on
  health
• Campbell S et al, NEJM 2007 (in press)

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Impact.?

• .for cardiovascular disease (CVD)

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Aberdeen Study Secondary Prevention of CHD

• Systematic nurse-led care results in improved
  uptake of prevention measures
• This leads to a 15 reduction in mortality at 4
  years, persisting at 10 years in spite of
  equality of risk factor reduction at 4 years
• Conclusion
  nurses save lives delay can prove fatal

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Nurse Led Secondary CHD Prevention Survival
Curve
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Control Group
Intervention Group

• Survival

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Time
4 Years
10 Years
Murchie P et al. BMJ 200332684-6
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UK QOF Early experience

• Some concerns expressed about gaming
  exception reporting of some patients this
  indicator doesnt apply to that patient
• Seems not to be an issue 5.3 exception
  reporting in year 2 of contract (range up to 28)
• NHS Information Centre. www.qof.ic.nhs.uk/

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UK QOF Early experience

• Serious concern that current payment system
  systematically penalises practices serving
  deprived populations with high morbidity
• Payment formula needs to encourage case finding
  not discourage it.
• Guthrie B et al. BJGP 200656836-41

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UK QOF Early experience

• Evidence shows that QOF scores lower in deprived
  areas.
• Varying interpretations but one group concludes
  that difference between affluent and deprived are
  small a considerable achievement for deprived
  practices.
• Doran T et al. NEJM 2006355375-84.

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UK QOF Early experience

• What about non-incentivised conditions?
• Evidence that care has not changed for the
  orphans not in QOF
• Risk that non-incentivised care may worsen one
  to watch.
• Steele N et al. BJGP 200757449-54.

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UK QOF Early experience

• Impact on professional values?
• Wide range of views (remembering radical change
  in contract no OOH work)
• Many GPs support QOF, others say a threat to
  holistic and caring aspects of role. Nurses
  morale may have suffered more regarding this.
• McDonald R et al. BMJ 2007 (in press).

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UK QOF Early experience

• Previous research shows that external incentives
  are most likely to strengthen internal motivation
  where they support existing values and may damage
  it when they do not.1
• Distorting effect on other aspects of care still
  unknown if the case then the proportion of
  income based on the QOF should be reduced 20 ?
  102
• 1 Deci EL et al. Psychol Bull 1999125627-68.
• 2 Roland M. BJGP 200757525-7.

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Variations in qualityPopulation factors

• Urban-rural location worsening gradient
  between cities and very remote areas
• Related more to organisational rather than
  clinical domains

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Variation in qualityPractice factors

• Partnership size large practices did better
• GP characteristics older age lower points more
  females higher organisational points
• Quality indicators QPA and training higher
  organisational points
• Dispensing practices lower clinical and
  organisational points

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UK QOF View from NZ

• Mix of indicators (criteria) looks like a
  hotchpotch of intermediate clinical and practice
  based outcomes
• We have looked in vain for evidence underpinning
  this radical, risk and very expensive policy
• Dee Mangin, Les Toop. BJGP 200757435-7

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UK QOF Early experience

• More attention required on promoting the
  importance of interpersonal aspects of care Cum
  Scientia Caritas underpinning the evidence base
  of caring, and the importance of this in relation
  to the quality of compassion and humanity going
  full circle to my first slide quality in
  relation to role core business
• Roland M. BJGP 200757525-7.

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Worth of QOF?

• Early days encouraging
• Massive increase in recording never
  mind the quality count the points
• Systematic care now happening evidence implies
  that this should increase life quality quantity
  for many patients

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QOF - Challenges

• While care may be more systematic it is not
  necessarily fair depending on age, sex,
  condition, deprivation status, practice
  characteristics and location
• Jury still out on morale, health inequalities,
  distorting effect, other matters

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Worth? Values

• New contract is a likely boon for evidence-based
  care
• Technical proficiency is not a substitute for
  compassionate care
• Contractual performance should not be confused
  with professionalism nor values

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QOF Overall

• Incentivised conditions have improved but not
  conditions without incentives.
• Improvements require rewards to be aligned to the
  values of staff being incentivised
• Sustained quality improvement, requires clear
  goals (vision), good teamwork (agreed values) and
  effective leadership

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Without vision, we perish without values, we
decaywithout leadership, we lose our way
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Improving Quality

• Putting quality on the map key principles
• Quality development early UK Quality and
  Outcomes Framework (QOF) experience
• Quality improvement - whats needed and whats
  next?

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Intermission
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In closing.
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It is not the strongest of the species that
survives, nor the most intelligent, but rather
the one most responsive to change

• Charles Darwin

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Predicting change can be difficult..particul
arly the future.

• Daniel Quayle

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Improving Quality in General Practice -in this
journey we have come far -but we have many miles
to go
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Thank youfor listening

• And thank you for your kindness!