Dr Mareeni Raymond is a GP in London, CCG lead for dementia in City and Hackney, and Managing Editor for BMJ Quality Improvement Reports.
I’ve just returned from the Royal College of General Practitioner’s conference in Liverpool and for those of you that haven’t heard, Jeremy Hunt, MP, took on questions from hundreds of GPs, many of whom expressed dissatisfaction with their increasing workloads. I, on the other hand, took on questions from a group of enthusiastic GPs, registrars, and students who wanted to know more about quality improvement, working as a salaried GP, and working for a CCG. For me, that was rather lovely.
The question that is asked most often is “how can a GP take part in quality improvement work at the same time as doing all the other hundreds of tasks that need to be done each day?” There are so many hurdles in the job, as well as new ones “created” by the higher powers, with more hoops to jump through to make sure that targets are reached and that practices remain financially viable. Honestly, these are excellent questions and it is true that being a GP is far from easy, especially right now.
My own answer to the question about taking part in quality improvement is a simple one, and one I feel really quite passionately about: we are taking part in quality improvement every day – and it is extremely important to let people know about that right now.
I think people have fixed beliefs about certain job roles, such as the public perception that all their GP does is see patients. After all, what do we do in those breaks of ours, apart from visit elderly patients, read all the letters received about our patients, interpret all the results of tests, and answer telephone queries from our colleagues outside of general practice? (This list could, of course, go on). Well, we also talk about how to make things better and then we try do something about it. (Sound familiar? Check out the PDSA cycle learning module).
Every week we meet and discuss how we can improve services for patients. We discuss complaints. We talk about staffing problems. We talk about telephone triage. We talk about patients who were admitted to hospital and how this could have been prevented by better community care. We meet with district nurses, community matrons, child safeguarding leads, health visitors, palliative care, and psychiatry services (to name a few) to discuss complex patients’ needs and how we can meet them better. We audit unplanned admissions, prescribing, referrals (to name a few) and discuss how we can improve their quality.
So we are already doing this every single week and recording it, as we have been doing for years. It takes years of such conversations, changes in practice and procedures, and repeated conversations for patient care to improve, and this quality improvement activity is embedded into general practice culture in the UK, and it is something we strive to do well. Yet the public, and indeed our hospital colleagues, may not be aware of this aspect of our work, and I think this is a shame. Even we, as GPs, are not aware that this work is beyond simple audit, it is quality improvement work, and it is worth sharing. If we were all aware then we may have a lot more respect and understanding of each other, and could spread our ways of working and our ideas with the world, and collaborate with the public and colleagues better.
Taking the step to publication is next, and some GPs have already published their quality improvement reports. Here are some examples:
Telephone consultations in primary care, how to improve their safety, effectiveness and quality by Muhammad Naseer Babar Khan. Here, a literature search was done on published articles on telehealthcare which resulted in devising a telephone consultation model. Following the proposed consultation model by healthcare staff, it has improved patient satisfaction survey from 75% to 94%, face to face consultation rate was reduced by 1.6%, and home visits were reduced by 2.9%.
Another project called “General Practice Locum Improvement Tool” by Christopher Weatherburn and Shawkat Hasan initiated a process where the locum GP was emailed after their session with a one question survey enquiring about improvement suggestions for that practice. Feedback from the practice to locums included personalised specific clinical guidance, suggestions for improving documentation, and ways to optimise referrals. As a direct result of this pilot a locum box has been implemented in this practice and plans are to rerun this tool periodically.
Sarah Eccles published a report recently about bowel cancer screening. Her practice used three interventions: letter encouragement, staff education to increase opportunistic promotion of screening, and calling non- responders to identify reasons for non-participation and encourage participation. This resulted in increased uptake in screening.
These are just a few examples, and these doctors were doing the kind of quality improvement work that GPs do all the time and which goes unpublished and unrecognised. Don’t be afraid to share the good work you are doing in quality improvement. By publishing it you can change the way people view general practice and influence others all over the world who are challenged by the same problems that we are trying to solve! Have a look at quality.bmj.com or email quality@bmj.com if you’d like to publish your work. There are also workbooks at the site specifically for GPs and CCGs to run diabetes, dementia and COPD quality improvement projects if you are stuck for ideas!