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A standards approach to clinical quality

Developing primary care in East Kent.

ImpAct bottom line

Why was the initiative launched?

The Primary Care Clinical Effectiveness programme (PRICCE) was launched in April 1998 to help general practitioners and primary care teams in East Kent to improve quality of care. The programme consists of a package of evidence-based criteria and developmental support to help primary care teams improve their care in a systematic way. A series of proxy measures complement the standards to allow progress to be measured. Practices are rewarded for demonstrating that they have met the clinical standards.

What is being done?

A set of clinical standards form the bedrock of the programme. They provide a framework within which general practitioners and their teams can improve their clinical services. The standards were developed by a multi-disciplinary team from the health authority, local primary care, and specialists from around the country. An important contribution was made also by the Health Services Accreditation Unit. Thirteen clinical conditions were chosen - those most common or which caused particular long-term problems for patients. The health authority also developed a set of standards to guide the development of primary care administrative systems.

Example of the local standards: Myocardial Infarction.

♦ All patients with a myocardial infarction since 1/4/1998 must have (specified) information recorded in their notes, unless a contraindication is documented.
♦ Data from the secondary sector, eg exercise test results, ECG results, lipid profile, review dates.
♦ Medication the patient is on and why: aspirin, beta blockers, ACE inhibitors.

The clinical standards specify the proportion of patients that should be recorded, eg by 1/4/99, 80% of MI patients should have this recorded (and 90% by 1/4/01).

Disease areas covered
Atrial fibrillation
Chronic heart failure
Urinary tract infection
High cholesterol
Myocardial infarction
Venous leg ulcers

How it works

GPs are invited to apply to join the programme - and if successful receive a grant £3,000 (per full time GP, per year) as a contribution to the costs of the work involved. They are free to use the grant in any way they choose. A series of ‘entry criteria' has been established - such as the availability of disease registers and written clinical protocols. GPs have to ‘sign-up' to audits to demonstrate compliance with the standards. Payment is subject to satisfactory progress reports. In 1998/99 102 GPs from 26 practices were accepted into the programme - about a quarter of the local practices.

Entry criteria - apply to all disease areas
Disease registers set up
Written protocols undertaken by team members
Complete audits undertaken to demonstrate compliance

Special arrangements have been made to enable practices working within deprived areas to join the programme - with an incremental approach to the achievement of standards.

Two main activities have been put in place to support practices' involvement in the programme.

  1. GP Support Groups allow problems being faced by individual GP and practices to be discussed and resolved. These are centred on local hospitals so that hospital consultants can support them. The groups are facilitated by staff from the health authority and encourage multi-disciplinary working. Typically the groups meet every two months with discussions covering a variety of topics from IT systems and data capture to questions about clinical practice. The meetings are approved for educational purposes and have been well received - a GP attending one of such meetings said:
    'It is good to be going to meetings which are truly educational and which actually make me change my practice'
  2. Support from the local MAAG office to explore questions about the presentation and interpretation of data and in devising suitable audits. The MAAG office has created a set of ‘Read' codes for use within the programme. All of the work undertaken between the practices and the MAAG remains confidential - with detailed reports not open to the health authority.

Does it work?

A number of benefits are emerging from informal discussions with practices and the Support Groups even though no formal evaluation has yet been established. Examples are:

Discussions in the Support Groups are showing that individual clinicians are starting to change the nature and quality of care they provide to patients. Practices are creating disease registers to allow them to recall patients so that their treatment can be reviewed. Even when the practice standards have not been met in full, significant improvements in outcomes for patients are already being secured.

• One GP has said ‘It's created a buzz in the practice and given us a very positive focus. Patient care has definitely improved'.

More productive contact between GPs and hospital consultants is evident - particularly where co-ordinated care is necessary to achieve the standards. Consultants are acquiring a better understanding of the needs of primary care. Two examples are:

• GPs were concerned that they would be unable to meet the agreed standards for the care of patients with diabetes because of variations in the services provided from local hospitals. Subsequent discussions between GPs and Consultants have encouraged the three local hospital laboratories to adopt common reporting standards - they previously had different reporting levels.
• The diagnosis of urinary infection in babies is difficult because of the difficulty in collecting urine samples. Following discussions between GPs and Consultants a novel and effective means of collecting samples through the use of sanitary towels has been developed.

Participation in the programme is changing the ways in which practice teams work together and placing emphasis on teamwork as well as clinical practice.

Tips for success

Some early pointers to success are :

√ Create ‘safe' occasions when questions about quality of clinical practice can be openly discussed. These occasions must allow individual clinicians - GPs and other disciplines - to voice their uncertainty and lack of knowledge. Help them to change - don't simply expect it to happen.
√ Success depends on effective and consistent use of information and IT systems. Experience has shown that practices with a history of activity in particular disease areas are able to achieve the standards. Conversely, where there has been little such history, practices are finding it difficult to meet the standards. Accurate, detailed databases and disease registers are the keys to success. However, building these is a significant workload for most practices - but the exercise will prove an invaluable way of discovering patients who were ‘slipping through the net'

To find out more contact

Dr Tony Snell
Medical Adviser
East Kent Health Authority
Protea House
Marine Parade

Telephone 01304 222230; Fax 01304 222239;

An information pack, including the detailed clinical standards for the thirteen conditions, entry criteria for the programme and proxy outcome measures being used in East Kent is available. It costs £10 to cover printing and postage.

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