Transcript Welcome to the Quality Summit 31 July 2014

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 FRCGP
Chair of Council
RCGP
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
Traditional NHS inflation 5%
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).
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
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
Population, million 32.5
2013
57
Change
+ 75%
Births, thousand
Deaths, thousand
929
550
700
500
− 25%
− 10%
Age 65 and over
Proportion
5%
17%
Number, million
1.6
9.7
Source: 2013 ONS, 1901 various web sites
6 times
Changes in cost and place
• 1900 minimum official • 2014 cost of GP
fee to consult GP 2s 6d consultation £60
• 1977 19% of all GP
consultations took
place in the home
Source: Roy Porter, 1997
• 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 Quality
from 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
NATIONAL SUMMIT ON QUALITY IN
GENERAL PRACTICE
Thursday 31 July 2014
9.30-4.00 p.m.
Welcome back
How can we
sustain and
improve quality?
Quality in General Practice
31 July 2014
Presentation title set in header
Who are we?
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.
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Improving Quality in Primary
Care: A Different Paradigm?
27
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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?
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
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Ten Challenges
Convincing people that there is a
problem
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Ten Challenges
Convincing people that there is a
problem
Convincing people that the solution
chosen is the right one
34
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Convincing people that the solution
chosen is the right one
Getting data collection and
monitoring systems right
35
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Convincing people that the solution
chosen is the right one
Getting data collection and monitoring
systems right
Excess ambitions and ‘projectness’
36
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Convincing people that the solution
chosen is the right one
Getting data collection and monitoring
systems right
Excess ambitions and ‘projectness’
The organisational context, culture
and capacities
37
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff
engagement
Convincing people that the solution
chosen is the right one
Getting data collection and monitoring
systems right
Excess ambitions and ‘projectness’
The organisational context, culture and
capacities
38
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Getting data collection and monitoring
systems right
Excess ambitions and ‘projectness’
The organisational context, culture and
capacities
39
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Balancing carrots and sticks –
harnessing commitment through
Getting data collection and monitoring
systems right
Excess ambitions and ‘projectness’
The organisational context, culture and
capacities
40
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Getting data collection and monitoring
systems right
Balancing carrots and sticks –
harnessing commitment through
Incentives and potential sanctions
Excess ambitions and ‘projectness’
The organisational context, culture and
capacities
41
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Balancing carrots and sticks –
harnessing commitment through
Getting data collection and monitoring
systems right
Incentives and potential sanctions
Excess ambitions and ‘projectness’
Securing sustainability
The organisational context, culture and
capacities
42
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Balancing carrots and sticks –
harnessing commitment through
Getting data collection and monitoring
systems right
Incentives and potential sanctions
Excess ambitions and ‘projectness’
Securing sustainability
The organisational context, culture and
capacities
Considering the side effects of
change
43
Presentation title set in header
Ten Challenges
Convincing people that there is a
problem
Tribalism and lack of staff engagement
Leadership
Convincing people that the solution
chosen is the right one
Balancing carrots and sticks –
harnessing commitment through
Getting data collection and monitoring
systems right
Incentives and potential sanctions
Excess ambitions and ‘projectness’
Securing sustainability
The organisational context, culture and
capacities
Considering the side effects of
change
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SCOTLAND –
SHARING OUR LEARNING
Quality Summit
RCGP London
31st July 2014
@brobson3
Dr Brian Robson, Health Foundation /IHI Fellow,
Executive Clinical Director, Healthcare Improvement Scotland
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
NATIONAL COMMITMENT TO QUALITY
3 Quality Ambitions
• Safe care
• Effective care
• Person-centred care
http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf Scottish Government, May 2010
Safety leading the way …
Acute
Maternity
Adult
and Children
SPSP
Mental
Primary
Health
Care
http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme
The Collaborative Model
Organisational
Self Assessment
P
A
P
D
1.5 day
Kickoff
A
D
A
LS
D
S
S
S
Alignment with
national work
P
LS
LS
Continued
Supports
Support to implement key changes, improvements and measurement:
•
•
•
•
Expert faculty
Site visits
WebEx
Progress Reviews
Institute for Healthcare Improvement
Institute for Healthcare Improvement
CLINICAL ENGAGEMENT STRATEGY
“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.”
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
1-2%
1-3
The incidence of adverse events in consultation in Primary Care
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.
8%
1
The incidence of adverse events in consultation in General Practice
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
25%
1,2
The incidence of adverse events in consultation in Primary Care
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.
CAUSES OF HARM
• Drug adverse events
“Absolute number of those harmed may be just
as large or greater than in secondary care”
Health Foundation 2011
• Medication errors
• Delayed diagnosis
• Clinical error
• Administration errors
• Results Systems
• Communication
• …
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)
100%
80%
60%
40%
20%
0%
28th 14th 28th 11th 25th 9th 23rd 6th 20th 4th 18th 1st 15th 29th 12th 26th 10th 24th 7th 21st 5th 19th 2nd
Feb Mar Mar Apr April May May June June July July Aug Aug Aug Sept Sept Oct Oct Nov Nov Dec Dec Jan
Our Ambition
To reduce the number of events
which cause avoidable harm to
people from healthcare
delivered in any primary care
setting.
Our Aim
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.
Focus in the first year
National (QOF)
– Trigger tool
(twice a year)
– Safety climate survey
(once a year)
Menu of local priorities
– Warfarin
– DMARDs
– Medicines
reconciliation
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
Medication
Reconciliation
DMARDS
NHS Ayrshire & Arran
NHS Forth Valley
NHS Greater Glasgow and
Clyde
NHS Lanarkshire
NHS Lothian
NHS Orkney
NHS Shetland
NHS Western Isles
NHS Tayside
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 aims
95% 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 Reconciliation
NHS 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
Community Pharmacy in Primary Care –
Our Aims
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
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
NATIONAL SUMMIT ON QUALITY IN
GENERAL PRACTICE
Thursday 31 July 2014
9.30-4.00 p.m.