welcome to the national summit on quality in general practice thursday 31 july 2014 9.30-4.00 p.m

Welcome to the

NATIONAL SUMMIT ON QUALITY IN GENERAL PRACTICE Thursday 31 July 2014

9.30-4.00 p.m.

General Practice Taking Stock

Dr Maureen Baker CBE DM FRCGPChair of CouncilRCGP

British General Practice

• Around 1.2m patients seen every working day

• Increase in consultations from 300.4m per annum in 2008 to 340m 2012 (latest figures)

• Increase in workload, static funding and falling resource is bringing general practice to its knees

Rising Demand Between 1995 and 2008, the number of consultations in General Practice rose by 75% to more than 300m. A sharp increase in consultations for those over 65 has contributed to this

The rise in numbers and complexity

“Epidemiology of Multimorbidity” – Lancet, May 2012

“Epidemiology of Multimorbidity”

Lancet, May 2012

A reminder about the money

arctic’ scenario: real funding cuts (-2 per cent for first three years, -1 per cent for second three years) ‘cold’ scenario: 0 per cent real growth in six years ‘tepid’ scenario: real increase (+2 per cent for first 3 years, then +3 per cent for the next three years).

Appleby J, Crawford R, Emmerson C. (2009) How cold will it be? http://www.kingsfund.org.uk/research/publications/ how_cold_will_it_be_html 2009).

Traditional NHS inflation 5%

http://http/www.kingsfund.org.uk/research/publications/%20how_cold_will_it_be_html

General practice funding has fallen by 8% across Britain in real terms since 2005/06 – at a time when the rest of the NHS budget has grown by 18%

Source: RCGP analysis

Not enough GPs: The general practice workforce crisis

Transformational change

• Extended general practice delivered at scale (federations, super-practices etc)

• Extended care of patients in their home (packages of care designed around patients’ needs)

• Most effective use of generalist and specialist skills (eg. specialist is consultant to generalist rather than patient)

• Clinical and admin teams working across interfaces (teams without walls)

Barriers to change

• Lack of funding• Lack of workforce• Evidence gap on both clinically effective and

cost effective management of multimorbidity• Current structures inhibit effective funding

models and effective teamworking

What must be done?• Better planned resource over health and social care

economy• Invest in general practice and community services

with a view to supporting patients at home and avoiding emergency admissions

• Mechanisms to allow effective teamworking across interfaces

• Support our campaign – Put Patients First: Back General Practice

• www.putpatientsfirst.rcgp.org.uk

http://www.putpatientsfirst.rcgp.org.uk/

National Summit on Quality in General Practice

Patricia Wilkie, OBE, PhD, FRCGP (Hon)President and Chairman

National Association for Patient Participation

Population changes

England & Wales

1901 2013 Change

Population, million 32.5 57 + 75%

Births, thousand 929 700 − 25%Deaths, thousand 550 500 − 10%

Age 65 and overProportion 5% 17%

Number, million 1.6 9.7 6 times

Source: 2013 ONS, 1901 various web sites

Changes in cost and place

• 1900 minimum official fee to consult GP 2s 6d

• 1977 19% of all GP consultations took place in the home

Source: Roy Porter, 1997

• 2014 cost of GP consultation £60

• 2014 negligible

Dawson report 1919• District hospitals and primary health

centres staffed by GPs• Outpatient clinics with visiting consultants• Theatres• X-Ray• Ambulance and “communal” services• Labs• Dentistry• Maternity

Where we are in General Practice• GP and patient capacity• Demographic changes• Decline in acute illnesses• Increase in chronic conditions • Movement from hospital to community care • Increasing costs of health care• Increase in specialism in secondary care

Definition of Qualityfrom Patient Perspective

The doctor• A Good Doctor - not an

aspiration• Clinically competent, good

diagnostician and up to date • Involvement in care and

wider health care • Evidence based outcomes• Continuity• Good listener• Felt that had enough time

The practice• Access - speed and

simplicity• Quick service for urgent

problem• Choice of practitioner • Responsive practice• Flexibility • Use of technology• Patient Participation

Group

Meeting the challenge:what needs to change 1

• More varied consultation formats • Better use of telephone, skype, email,

telehealth • Implications for patients, GPs and practice• Patients with several LTCs, carers, GPs

and team to agree most appropriate way of working

• Readily available outcome data • PPG in every practice

Meeting the challenge:what needs to change 2

• Appropriate funding of GP services• GP services are mainly free at point of

delivery. Patients and the public now need to know the cost of running services. This information is necessary for us to be responsible citizens

I want it now! Doing better feeling worse

• Medicine is a victim of its own success leading to increased expectations

• These expectations may be unlimited and may be unfulfillable

• We all have to redefine what is possible • This can only be done in real partnership

between patients and doctors• Put patients first and back general practice

Welcome to the


9.30-4.00 p.m.

Welcome back

How can we sustain and improve quality?Quality in General Practice31 July 2014

Who are we?

Presentation title set in header

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The Health Foundation is an independent charity working to improve the quality of healthcare in the UK.

We are here to support people working in healthcare practice and policy to make lasting improvements to health services.

We carry out research and in-depth policy analysis, run improvement programmes to put ideas into practice in the NHS, support and develop leaders and share evidence to encourage wider change.

Improving Quality in Primary Care: A Different Paradigm?


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Different scale


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Different safety challenges


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Different ways of working


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Different settings for care


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What do we know?


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Overcoming Challenges to Improving Quality

– 14 Evaluation Reports (approx £40m improvement investment)

– Range of sectors- but predominantly acute

– Range of projects- but all about improving quality of clinical care

– 10 generic themes

Ten Challenges

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Convincing people that there is a problem


Ten Challenges

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Convincing people that the solution chosen is the right one


Ten Challenges

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Getting data collection and monitoring systems right


Ten Challenges

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Excess ambitions and ‘projectness’


Ten Challenges

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The organisational context, culture and capacities


Ten Challenges

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Tribalism and lack of staff engagement


Ten Challenges

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Leadership


Ten Challenges

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Leadership

Balancing carrots and sticks – harnessing commitment through


Ten Challenges

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Leadership


Incentives and potential sanctions


Ten Challenges

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Leadership



Securing sustainability


Ten Challenges

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Leadership




Considering the side effects of change


Ten Challenges

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Leadership




Considering the side effects of change


Quality Summit

RCGP London

31st July 2014

Dr Brian Robson, Health Foundation /IHI Fellow,

Executive Clinical Director, Healthcare Improvement Scotland

SCOTLAND – SHARING OUR LEARNING

@brobson3

SCOTLAND’S QUALITY JOURNEY

‘This is not the end.

It is not even the beginning of the end, but it is, perhaps, the end of

the beginning.’

Sir Winston Churchill

As at 30/7/14

Context is everything

• 5 million population

• £11.4 billion health budget

• Integrated health and social care system

• 14 territorial boards

• 1,000 Independent GP practices with 4,000 GPs

http://www.google.com/url?sa=i&rct=j&q=map+of+scotland&source=images&cd=&cad=rja&docid=eXZhPefi65AVOM&tbnid=UYK8Iie-TcGG3M:&ved=0CAUQjRw&url=http://www.welt-atlas.de/map_of_scotland_politically_1-440&ei=Ze_8UtPQC_Ka1AX49IGoAg&bvm=bv.61190604,d.ZGU&psig=AFQjCNFFxpw5Q7ikwKATi3u-8y5QMrcYLQ&ust=1392394446844110

NATIONAL COMMITMENT TO QUALITY

http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf Scottish Government, May 2010

3 Quality Ambitions• Safe care• Effective care• Person-centred care

http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf

Acute Adult

Maternity and Children

Mental Health

Primary Care

SPSP

Safety leading the way …

http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme

http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme

The Collaborative Model

LSAlignment with national work

LS

A

P

D

S

A D

P

S

1.5 day Kickoff

D

S

P

A

LS

OrganisationalSelf Assessment

Continued Supports

Institute for Healthcare Improvement

Support to implement key changes, improvements and measurement:

• Expert faculty• Site visits• WebEx• Progress Reviews

Institute for Healthcare Improvement

“to ensure all of our activities, from planning to delivery, are influenced by clinical communities, and that a progressive and sustainable approach to engaging clinicians is firmly embedded.”

CLINICAL ENGAGEMENT STRATEGY

http://www.healthcareimprovementscotland.org/our_work/clinical_engagement.aspx

http://www.healthcareimprovementscotland.org/our_work/clinical_engagement.aspx

NOT JUST PLUG AND PLAY ...

• History of commitment to quality

• Small units

• Change happens

• Change can be rapid

• Minimal bureacracy

• Multiple levers – professional, business, contract, ...

Patient permission granted

The incidence of adverse events in consultation in Primary Care

1-2%1. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003; 20(3):231-6. 2. de Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J 2009; 85(1002):176-80. 3. Tsang C, Majeed A, Banarsee R, Gnani S, Aylin P. Recording of adverse events in English general practice: analysis of data from electronic patient records. Inform Prim Care 2010; 18(2):117-24.

1-3

The incidence of adverse events in consultation in General Practice

8%1. Rubin G, George A, Chinn DJ, Richardson C. Errors in general practice: development of an error classification and pilot study of a method for detecting errors. Qual Saf Health Care 2003; 12:443-7

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The incidence of adverse events in consultation in Primary Care

25%1. Elder NC, Vonder Meulen M, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Ann Fam Med 2004; 2(2):125-9. 2. Kistler CE, Walter LC, Mitchell CM, Sloane PD. Patient perceptions of mistakes in ambulatory care. Arch Intern Med 2010; 170(16):1480-7.

1,2

CAUSES OF HARM

• Drug adverse events

• Medication errors

• Delayed diagnosis

• Clinical error

• Administration errors

• Results Systems

• Communication

• …http://www.health.org.uk/publications/levels-of-harm-in-primary-care

“Absolute number of those harmed may be just as large or greater than in secondary care”

Health Foundation 2011

http://www.health.org.uk/publications/levels-of-harm-in-primary-care

DEVELOPMENT AND TESTING SAFETY IMPROVEMENT IN PRIMARY CARE 1

•Care bundles•Safety Climate Surveys•QI Methods and skills

Methotrexate Bundle

• Full blood count in the past 6 weeks?• Abnormal results acted on? • Review of blood tests prior to issue of last

prescription? • Had pneumococcal vaccine?• Patient asked about side effects since last time blood

was taken?

• Compliance with all of the above.

WARFARIN BUNDLE COMPLIANCE

Overall Warfarin Bundle Compliance (Wave 1)

0%

20%

40%

60%

80%

100%

28thFeb

14thMar

28thMar

11thApr

25thApril

9thMay

23rdMay

6thJune

20thJune

4thJuly

18thJuly

1stAug

15thAug

29thAug

12thSept

26thSept

10thOct

24thOct

7thNov

21stNov

5thDec

19thDec

2ndJan

Our Ambition

To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.

All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.

Our Aim

National (QOF)– Trigger tool

(twice a year)– Safety climate survey

(once a year)

Menu of local priorities– Warfarin– DMARDs – Medicines

reconciliation

Focus in the first year

Health Board areas of focus

Warfarin

NHS Ayrshire & Arran

NHS Borders

NHS Dumfries & Galloway

NHS Fife

NHS Forth Valley

NHS Grampian

NHS Highland

NHS Lothian

DMARDS

NHS Forth Valley

NHS Lanarkshire

NHS Tayside

Medication Reconciliation

NHS Ayrshire & Arran

NHS Greater Glasgow and Clyde

NHS Lothian

NHS Orkney

NHS Shetland

NHS Western Isles

Progress towards our aims

95% of practices undertaking Safety Climate Surveys, by April 2014

• 90% of practices completed the Safety Climate Survey in year 1

Culture eats strategy for breakfast

Anon

SAFETY CLIMATE SURVEY

• On line

• Practice report

• Measurement

• Diagnosis

• Catalyst for change

Much of the value of these types of surveys lies in raising the profile of patient safety and promoting conversations, .... that’s when the improvements come through

The Health Foundation, 2011

Progress towards our aims95% of practices implement systems for reliable prescribing and monitoring of high risk medications by 2016, eg Warfarin, Methotrexate

• 83% of practices in year 1 engaged in improving reliability of one high risk medication

Medicines ReconciliationNHS Ayrshire and Arran

Compliance with bundle May 2013 Compliance with bundle – Feb 2014

Overall

• 82% said the programme had benefited their practice

• 75% said the Programme had improved the safety culture of their practice

Improve patient safety by strengthening the contribution of pharmacists to :

• Improve the reliability medication reconciliation when patients are discharged from hospital

• Deliver reliable processes underpinning the safe prescribing

monitoring dispensing and administering of high risk medications

• Improve the safety culture of pharmacy teams in the community

Community Pharmacy in Primary Care – Our Aims

July 2014 - Developing a Quality Framework for General Practice in Scotland

• Map current state quality activities

• Identify gaps and omissions • Reflect future developments

in General Practice• Recommendations for key

players to fill the gaps

Recommendations

• Standards – self and peer review

• Guidance to existing QI resources

• Multimorbidity evidence base guidelines

• Locality QI support – facilitation, data analysis, QI methods and tools

• Increased patient involvement and engagement at practice level

• Increased awareness of community resources and assets for General Practice

• Leadership development for quality improvement

IN SUMMARY

• National quality strategy

• Context – size, alignment, pace

• Collaborative improvement

• Improvement method(s)

• Patients at the centre

• QI in primary care/ localities

Thank You@brobson3

[email protected]

Welcome back

Welcome to the


9.30-4.00 p.m.

welcome to the national summit on quality in general practice thursday 31 july 2014 9.30-4.00 p.m

Documents