Policy bite: Quality in primary care – walking the walk.

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Professor Amanda Howe, our President–Elect, said in her speech at the WONCA Council in 2013 that she would “help with policy messages. This is her monthly "Policy Bite". We are also inviting you to send us similar material - an important piece of policy from your own organisation or setting that relates to family medicine developments and that might be helpful to others. Please send a summary, a link, and make it short - its not Twitter, we shall allow up to 500 word. email to editor@wonca.net

I have just finished writing a paper for the Council of my member organisation (Royal College of General Practitioners) to consider. We want to review what we do via our members for patient quality of care – not just safe care, not even just quality checks, but quality improvement. This means first of all knowing what we are aiming to achieve – our recent NHS contract has five domains so we can be in no doubt!

1. Preventing people from dying prematurely
2. Enhancing quality of life for people with long term conditions
3. Helping people to recover from episodes of ill health or following injury
4. Ensuring that people have a positive experience of care
5. Treating and caring for people in a safe environment and protecting them from avoidable harm .

But these are high level outcomes, and community based clinics have different patients from hospital settings. WHO offers six domains by which we can measure quality of care - care that is “effective, efficient, accessible, acceptable to patients, equitable and safe”. All very important – but how do you judge that in daily practice?

For busy family medicine doctors, we often start from problems – things that have gone wrong, where patients have complained, or we know ourselves that things could have been done better. Three tips for quality improvement – don’t jump to conclusions: look at what happened, what else we can find out about the background to the problem, and what could have been done differently that might have led to a better outcome . Then make a good space to discuss it, especially if people are feeling upset or defensive – i.e. not in the corridor at the end of a busy day, when everyone is tired and it can all be overheard! And turn every problem into a proposal for improvement – it encourages people to think they won’t have to go through all that upset again.

Patterns matter too – data on what the commonest problems were last month can be a rich source for analysis and making changes. In one UK general practice, a simple audit of how often patients had to come in to get prescriptions rechecked or items renewed led to a whole new system which was much more efficient –patients liked getting everything sorted on one occasion as well as staff! Supply chain problems such as lack of vaccine availability or disposable gloves also need auditing and reporting – sometimes firm quantitative evidence of a problem forces people to act when a personal complaint goes unheard.

One of the tenets of quality improvement science is that you must look at things at an individual, team and organizational level. Too often, I will be doing the right thing in my room, but ‘the system’ is not efficient because it is calling people back too often, or not enough – or not keeping track of the people who have not had their diabetes checks – or not offering enough telephone lines for the patients’ enquiries ……….. Please fill in your own examples here!

Again, talking to the team, just like listening to patients, can bring out both problems and solutions – and also reduce clinician stress and burnout. The cycle of ‘Plan, Do, Study, Act’ is both professional (analytic, controlled, reflective) and motivating, because it allows a sense of shared purpose while being open to different answers. And it makes us look at all the levels where changes put together can bring about improvement.

It’s hard work of course – and often taking everyone in the team with you is the hardest bit. But if we are to persuade people that family medicine is an important speciality with something to offer, we have to offer quality. And it can be fun!

Aim high, but be realistic, and be persistent – as Gandhi is reputed to have said, “You must be the change you want to see in the world”– others will follow.