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TheHealthFoundation’sEngagingwith QualityinPrimaryCare

Jo Parish,Andy Brown and Zoe Ward*

Media and Communications Officer

Web and Publications Editor

Public Affairs Advisor, The Health Foundation, London, UK

Corresponding Author:
Zoe Ward
Public Affairs Advisor
The Health Foundation, 90 LongAcre
LondonWC2E 9RA, UK
Tel: +44 (0)20 7257 8051
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Email: [email protected]
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Over 80% of contact between the public and the health service takes place in primary care settings. However, as with other areas of health care, there is a gap between known best practice and everyday care. In March 2007, The Health Foundation announced the winners of its £5.5 million Engaging with Quality in Primary Care scheme. Over the next three years, nine project teams will work to engage primary care clinicians in the quality improvement process and, by doing so, increase capacity for improvements in clinical quality in primary care in the UK.

The project teams have all identified a gap between the current quality of clinical care and evidence of best practice and will beworking hard to close these gaps in a diverse range of areas including domestic violence, back pain and insomnia. The teams are all multiprofessional and include patients or their representatives.

Below is a summary of the nine projects including their aims, ambitions and future plans for sharing their findings.

A quality outcomes framework for gastrointestinal disorders

Lead organisation: CORE: The Digestive Disorders Foundation

Partners: King’s College, University of London, National Association for Crohn’s and Colitis, Coeliac UK,

Irritable Bowel Syndrome Network, Primary Care

Society for Gastroenterology, British Society of Gastroenterology, University of Oxford

Around 10% of work in general practice and hospital medicine is to do with digestive disorders. However, while the Quality and Outcomes Framework has targets for managing many chronic diseases, such as diabetes, heart disease and chronic pulmonary disease, there currently aren’t any equivalent criteria for good management for gastrointestinal problems.

The project aims to address this problem by developing guidelines for four gastrointestinal disorders. These are: reflux disease, which is an acid-related problem in the stomach and oesophagus; irritable bowel syndrome (IBS), which is unpleasant but not deadly; inflammatory bowel disease (IBD), which is rarer but more serious; and coeliac disease, a condition in which the patient cannot absorb certain foods.

A key focus for the team is to ensure that guidelines for these conditions incorporate the patient perspective. The first phase of the study will therefore be to run a series of focus groups with the National Association for Crohn’s and Colitis, Coeliac UK and the IBS Network to find out what patients think represents good-quality care. The second phase will be a review of existing evidence and guidance, and the third will be to synthesise the current guidance with the new findings on patients’ requirements.

If the project is successful, the team hopes to see their work incorporated into the Quality and Outcomes Framework. In addition, they plan to generate a series of computer-generated prompts for general practitioners (GPs) and hope to use their findings to influence practice-based commissioning.

A whole-system approach to quality improvement

Project lead: Milton Keynes Primary Care Trust

Partners: Milton Keynes Practice Based Commissioning

Collaborative, University of Oxford, Department of

Primary Health Care and Centre for Evidence Based

Medicine, Milton Keynes Patient Forum

In 1999, the government published The NHS Plan, which aimed to make the health service more patient centred. Recent policy documents have built on this ambition and have set out plans to move healthcare services out of hospitals into primary care, and for GPs to become more involved in commissioning services.

This project will be looking at ways of developing practice-based commissioning that ensure it is primary care led, patient centred and evidence based. ‘Put simply, the aim of our project is to improve on each of these three aspects, which are lacking in the NHS at present, in order to improve the quality of care for patients’, project lead Dr Nicholas Hicks says.

The project team will start by working with the Patients’ Forum and GP practices across Milton Keynes to identify areas for improvement. The list of potential areas includes diabetes mellitus, chronic obstructive pulmonary disease and asthma, cardiovascular disease, terminal care, depression, promoting appropriate attendance at accident and emergency departments and the management of suspected deep vein thrombosis. The project may also look at communication between GPs and consultants.

Local librarians and the Centre for Evidence Based Medicine at Oxford University will thenwork with the Patients’ Forum and the GP practices to understand the evidence base in the different areas. Individual practices across Milton Keynes will lead on different clinical areas and spread their improvement to all of the GP practices involved in the project. The team hopes that this collaborative approach will lead to larger-scale changes than would otherwise be possible.

By the end of the project, the team wants to see quantifiable improvements in the quality of care. However, Dr Hicks adds, ‘Just as important will be changes in the way of working. The approaches that have led to those changes will be embedded across the health community and the public will be involved every step of the way’.

Equity, ethnicity and expert patients

Lead organisation: The Clinical Effectiveness Group, Centre for Health Science, Queen Mary University of London

Partners: Tower Hamlets Primary Care Trust, Social Action for Health, City University London

Although Tower Hamlets has a young, transient and diverse population, health is poor and the borough ranks as one of the most deprived communities in the UK. The low life expectancy in Tower Hamlets means that it comes within the government’s ‘spearhead’ areas with a target to reduce health inequalities by 10% by 2010, asmeasured by infant mortality and life expectancy at birth.

Encompassing all the GP practices in Tower Hamlets, this project aims to reduce inequalities in how health care is delivered, and ultimately in the health of the population. The team plans to do this in two ways: first, by supporting GPs to identify and understand inequality in their practice and to provide a better and more equitable service. Secondly, the team intends to work with professionals and patients to develop selfmanagement programmes and to improve the public’s awareness of their right of access to healthcare services.

The project team has chosen to focus on the three disease areas which contribute most to poor health in Tower Hamlets. These are diabetes, cardiovascular disease and chronic obstructive pulmonary disease (COPD). Through the collection of baseline data from GP practices, they plan to monitor how individual practices are performing in relation to their peers. They will compare service provision both across the borough and against national guidelines. The team will then work with the practices to analyse the data and seek to understand how to improve their services. The methods will include education, facilitated support within practices and using IT systems to support case management. Working with patient groups, the team will also develop a package of measures to help patients work in partnershipwith their GPs to manage their own condition more effectively.

The team hopes that this project will help those people most at risk of COPD, heart disease and diabetes in Tower Hamlets to access the right services and to receive appropriate treatment. Ultimately, they expect this to minimise the effect of these diseases in the borough.

Implementing evidence-based primary care for back pain

Lead organisation: Keele University

Partners: The Primary Care Musculoskeletal Research Centre, Central and East Cheshire Primary Care Trust

Four out of five people will experience back pain at some point in their lives. For some people it will be a chronic debilitating problem which affects their ability to work, socialise and have a family life. Back pain is also costly for society. The charity BackCare has estimated that nearly five million working days per year are lost through bad backs. Back pain also accounts for around 10% of GPs’ appointments and costs the NHS around £1 billion.

This project aims to improve the care of people with back pain by training GPs and physiotherapists in how to identify which treatment is most appropriate for different types of patients, and how to deliver that treatment.

Professor Elaine Hay, the project lead, explains, ‘We know that people with pain and disability will respond to various manual techniques of physiotherapy andwe know that people with psychological distress may need a cognitive psychological approach. However, what practitioners don’t know at the moment is how to decide who should get which treatment. So we’ve worked out a way of dividing patients into three types and have developed programmes to train physiotherapists to deliver different interventions for each group’.

The project team will implement this technique in GP practices and community physiotherapy centres in the Central and East Cheshire Primary Care Trust. Their main way of doing this will be through a patient questionnaire. The project will also train physiotherapists to deliver the different types of intervention.

In terms of spreading the learning from the project, Elaine hopes that the physiotherapy interventions the team has developed may be incorporated into accredited postgraduate training. ‘We want to try and influence policy through input into the National Institute for Health and Clinical Excellence low back pain guidelines and through the Department of Health strategies’, Professor Hay adds.

Improving the management of back pain

Lead organisation: Bournemouth University

Partners: BackCare, South Wiltshire Health and Social Care Academy, Severn Wessex Deanery, Bournemouth and Poole and South Wiltshire Primary Care Trusts

As with ‘Implementing evidence based primary care for back pain’, this project aims to improve the care of people with back pain. Specifically, the team aims to give GP practices the skills to better manage the treatment of patients with back pain.

‘We have become aware that treating back pain is inconsistent across primary care’, project lead Dr Charles Campion Smith says. ‘I think there have been problems in applying evidence from studies to an individual person in front of you with needs and expectations. There are also some knowledge gaps and what we might call myths about using pain relief in back care.’

The project team will work with ten practices across two primary care trusts. They will ask the practice teams to rate their confidence and skills and get them to share their stories using a narrative approach to learning about patients. In addition to gathering patient stories, the team also plans to conduct detailed survey work to look at how the project impacts on patient care.

The team will work with the practices in small groups, using an action learning set approach. These will be interprofessional and patients will be invited to join the groups. The team is also planning to link up with local expert patient groups. At the end of the project, the team hopes the practices will have greater confidence in working with patients to manage back pain.

In addition to improving the management of back pain, the team also hopes that learning from their work may apply to other clinical areas.

Improving the quality of mental health in secondary schools

Lead organisation: Institute of Psychiatry, King’s College London

Partners: Charlie Waller Memorial Trust, Community

Practitioners and Health Visitors Association, Rethink,

Royal College of Nursing, Sutton and Merton Primary Care Trust

According to Rethink, between 10% and 20% of children and young people have a mental health problem, some of whom will have a severe mental illness. School nurses have a pivotal role in spotting mental health problems in adolescents but, at present, are under-trained in mental health work. This project aims to provide them with training and support in learning how to recognise and treat mental health problems at school.

Drawing on the expertise of two members of the multidisciplinary project team, who are school nurses at Sutton and Merton, the team aims to do two things.

The first is to train school nurses to be better at recognising and assessing mental health problems, and to know when to refer people for help and when to manage children’s mental health themselves. This will involve collating existing training material and developing new tools, including video-based learning.

Secondly, the team wants to develop more support systems for school nurses as a professional group. This would include networks of peer support, so they can meet together, learn together and discuss children that they’ve seen as well.

If the pilot project is successful, young people with mental health problems will get spotted much earlier and receive effective treatment. ‘This will help them in several ways’, explains project lead, Andre´ Tylee, from the Institute of Psychiatry, King’s College London. ‘It will help their quality of life, their attainment at school, their health in general and their emotional well-being.’

In order to make the project sustainable, the team is working with existing school nurse networks in London and the south east of England, including the Royal College of Nursing. ‘We hope that when we’ve packed our bags and gone in three years’ time there’ll be an active network of school nurses who have an interest in sharing their experiences in mental health andwho will work and learn together’, Andre´ concludes.

Primary care domestic violence programme

Lead organisation: Queen Mary, University of London

Partners: London South Bank University, the University of Bristol, The Nia project, Bristol NextLink, Safer

Bristol, Bristol Primary Care Trust and City and Hackney Primary Care Trust

Domestic violence is any physical, sexual or psychological abuse that takes place within an intimate relationship and that forms a pattern of coercive and controlling behaviour. The British Crime Survey in 2004 found that 13% of women experienced domestic violence, sexual victimisation or stalking in the past year. This rises to 45% lifetime prevalence for women. Domestic violence damages women’s physical and mental health and has long-term health and educational consequences for their children.

This project aims to tackle the mismatch between the large public health problem presented by domestic violence and the poor response from the NHS in general, and from primary care in particular. ‘We haven’t yet found a way of responding appropriately and providing a quality service in relation to partner violence’, project lead Professor Gene Feder says. ‘Women experiencing violence often want to disclose this to healthcare professionals they trust, yet primary care services have lagged behind other agencies in identifying women at risk and developing effective support.’

The team is setting up a randomised controlled trial to test an educational and support programme for GP practices, which aims to help them identify and refer patients who are experiencing domestic violence. A key aspect is the partnership with voluntary agencies, which are currently providing most of the expertise for women experiencing domestic violence.

The trial name is Identification and Referral to Improve Safety (IRIS). Iris was a messenger for the Greek Gods, symbolised by the rainbow, and carried a herald’s staff. This prefigures the universal symbol of healing: a rod with two intertwined snakes.

The new approach is being trialled in Bristol and east London. ‘At the end of three years, we hope to have good evidence that we can make a difference in terms of identification and referral, as well as outcomes for women taking up referral to domestic violence advocacy’, says Professor Feder. Ultimately, the team hopes the approach will be taken up as a model in other primary care trusts. If successful, it could be used to commission services nationally and to inform the general practice Quality and Outcomes Framework.

Quality improvement in chronic kidney disease

Lead organisations: St George’s, University of London and Kidney Research UK

Partners: Renal Association, Royal College of General Practitioners

The role of the kidneys is to remove waste products and extra fluid from the bloodstream. They also help control blood pressure and stimulate the production of red blood cells. In the case of patients with chronic kidney disease, waste products remain in their blood and they can be prone to anaemia, cardiovascular disease, renal failure and ultimately death.

This project aims to help GPs in south west London and Surrey better identify and manage patients with the condition. The team is looking at three different quality-improvement techniques. These techniques will be run in separate practices, while a fourth practice will be measured without any intervention to provide a baseline comparison.

Firstly, a patient-empowerment programme will try to increase patients’ understanding of the disease and its implications for their lifestyle. Secondly, auditbased education will be used to feed back data to groups of practices about their quality of care, with a local clinical champion presenting comparative data in an educational context. Thirdly, the team will work with a practice keen to offer new ways of looking after people with chronic kidney disease.

In an attempt to ensure the findings can be generalised, the project will take place in eight areas: four in the north of England and four in the south. Inner-city and suburban practices will be paired so that there is a mixture of types of practices in each intervention.

If the project is successful, the team hopes to interest primary care trust commissioning teams in their findings. ‘If the lessons for this are going to be shared, then the critical people are commissioners in the eight different areas this study will cover’, project clinical lead, Dr Simon de Lusignan, explains. ‘The biggest challenge is getting the methodology right so we can ascribe change to interventions in a way that will convince the commissioners that these are the strands of quality improvement that are really worth embedding in the NHS in the medium to long term.’

Resources for effective sleep treatment

Lead organisation: Lincolnshire Teaching Primary Care Trust

Partners: The Universities of Lincoln and Nottingham, the Centre for Health Improvement and Leadership in Lincoln, the East Midlands Mental Health Research Network Hub, Lincolnshire and Nottinghamshire Mental Health Trusts and the Trent Research and Development Support Unit

Around one in ten people suffer chronic insomnia, which occurs on a regular basis or over a long period of time. It is most commonly caused by stress and worry but can also be triggered by pain, noise, medication, depression and shift work. Insomnia contributes to daytime tiredness, which in turn can lead to accidents, illness, and work and relationship problems.

This project aims to improve treatment for people with insomnia by promoting a range of treatment options beyond sleeping pills, which are not always the most appropriate course of action and carry the risk of side-effects and addiction. The project is trying to discourage GPs from prescribing sleeping pills as a first-line response, and to encourage them to explore other treatment options first, which may be more in line with what patients actually need.

Some of the alternative treatments available include sleep hygiene and sleep restriction. ‘Sleep hygiene is really a bundle of things which aim to regulate sleep patterns’, project lead Professor Niroshan Siriwardena of the University of Lincoln and Editor of Quality in Primary Care explains. ‘It includes avoiding things like caffeine, alcohol, exercise and eating late in the evening. Sleep restriction means initially going to sleep later to ensure good quality sleep, making sure you wake up at the same time every day, which is better for your body clock, and then gradually moving back your time to go to sleep.’

The team is also planning to work with patients to understand what they need from a consultation for insomnia, and to work with a number of practices and primary care teams to test the impact of different approaches.

The team intends to present data back to practices and to analyse whether prescribing changes as a result of their new approach. If specific measures or combinations of measures are successful in the pilot areas, they plan to use opinion leaders to spread the changes and learning more widely. They also hope to link with commissioners in the county and to develop learning materials with the Centre for Health Improvement in Leadership in Lincolnshire.

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