Dr John Oldham, Head of the National Primary Care Development Team

The National Primary Care Development Team (NPDT) was established in February 2000 to run the National Primary Care Collaborative, a programme designed to spread best practice and methods of improvement. Three specific aspects of the patient pathway are covered:

  • Access to primary care
  • Care for patients with proven coronary heart disease
  • Access to routine secondary care services.

By January 2002 the NPDT was working with 1000 practices covering 7 million patients: the largest improvement programme in the world.

However, the strategic aim of the NPDT is to create capacity and capability for quality improvement in PCTs and practices; the Collaborative is simply the vehicle. It achieves this by having a small central team and maximising resources to develop the skills of staff in PCTs and practices throughout England. Participants can then apply the knowledge they gain in improvement science to their own priorities.

From the cohort of project managers and sites on the national waves we have selected 11 to become NPDT centres. Each centre will operate a collaborative covering 3-4 strategic health authorities under the supervision and training of the national team so that all PCTs can become engaged.

NPDT also integrates other activities with its strategic aim, creating templates for pathways between primary and secondary care (Smart Care Programme), working with local residents to drive improvement in deprived communities (Healthy Communities Collaborative) and working on areas of inter-agency improvement, particularly health and social care.

The National Primary Care Collaborative

Since the Collaborative started in June 2000, four waves, consisting of 20 primary care organisations in each and more than 400 practices in total, have participated. The Collaborative°s approach involves identifying existing best practice through an expert panel and disseminating and developing the knowledge gained via a series of three learning workshops and action periods in between.

The participating doctors, nurses and administrative staff use an improvement method based on small, rapid cycles of change and record monthly measures of improvement. They are supported by a project manager. While all the components are important, the key driving force is the motivation of the participants to improve care for patients.

Improving access to primary care

Access to primary care for patients can be improved using a model called ´advanced access°. This focuses on the following areas to achieve the greatest improvements:

  • Understanding demand
  • Shaping the handling of demand
  • Matching capacity to meet shaped demand
  • Developing contingency plans to sustain the system
  • Communicating effectively with the team and with patients

Using advanced access, practices have demonstrated that:

  • Telephone follow-up consultations reduce face to face consultations by up to 20% and are more convenient for patients and the practice
  • Telephone management of same-day appointment requests reduces face to face consultation by 30-50%
  • amail and websites can be successfully used for repeat prescribing requests, health queries, and self-help materials and programmes
  • Advanced access can dramatically reduce DNAs.

Practices that are using advanced access keep daily capacity and demand in equilibrium, and are able to offer patients a choice of ways to gain access to appropriate health care. Improvements in their ways of working using this system can level out, or even reduce, demand for home visits, out of hours consultations and face to face consultations. In addition, patient, staff and clinician satisfaction increases.

The Collaborative uses the measure of third available appointment to reflect routine access to every GP and nurse in a practice.

The practices and primary care organisations in the Collaborative have delivered:

  • A reduction of over 60% in waiting times for GPs
  • A reduction of over 50% in waiting times for nurses in the first, second and third waves
  • Wave on wave improvement.

Each wave has delivered a faster rate of improvement, demonstrating that through our expanding knowledge and the increasing weight of evidence gathered from earlier waves we were able to shorten the learning experience in subsequent waves. The next logical step was to consider how the accumulated knowledge might be shared even more quickly and on a much larger scale.

In December 2001, the 11 sites selected to become NPDT centres began to provide local support for the roll-out of improvements in primary care access throughout England. In addition to running a local collaborative, each centre will act as a point of contact, information and training.

By the end of 2002 NPDT will have worked with double the number of practices (a further 2200) in half the time of the previous national waves.

In addition, NPDT has provided funding for an access facilitator in each PCT that has not yet been involved in the Collaborative. NPDT will train these facilitators centrally in quality improvement techniques.

Improving care for patients with proven CHD

Evidence suggests that 76% of the reduction in cardiac event mortality of patients with proven CHD is achieved by ensuring that patients %re receiving appropriate medication. The work of the Collaborative on CHD focuses initially on ensuring that this is the case and that practices have reliable, valid registers; the improvement has been impressive.

However, most of the CHD work is about developing systems to ensure that patients are part of a proactive care programme. This includes regular medication review, lifestyle advice (diet, smoking and exercise), and management of blood pressure that will add years to life and life to years.

Practices use the improvement model (PDSA) to introduce changes in the way that they manage their registers and care for patients on an ongoing basis. Best practice in this area relates to:

  • Developing systems for maintaining validated CHD registers
  • Implementing practice agreed protocols
  • Developing computer templates for protocols
  • Running nurse led clinics.

These have brought significant improvements and first wave practices have delivered:

  • A 27% increase in CHD patients on aspirin (from a high baseline)
  • A 63% increase in CHD patients on statins
  • A 76% increase in CHD patients on ß/blockers 12 months post-myocardial infarction
  • A 16% increase in CHD patients with blood pressure less than 140/85 mmHg

The improvements achieved in first wave practices in their first year equate to a reduction in the relative risk of mortality from CHD of 34%.

Managing capacity and demand

Participating primary care organisations are able to reduce delays in the patient°s journey between primary and secondary care by understanding and managing capacity and demand and redesigning care pathways.

Primary care organisations identify strategic priorities and specialties with delay problems. They then work with primary and secondary care professionals, using redesign tools, to create improved pathways of care and to reduce delays in these areas.

Work in this area has shown that:

  • Measurement to understand demand and track improvement is crucial.
  • Process mapping of the patient journey is essential to understand flow, identify reasons for delay and explore alternative approaches to care provision.
  • Alternatives to traditional means of handling demand (e.g. GP specialists, specialist nurses) can reduce delays and increase accessibility.
  • The advanced access model can be successfully applied at the primary/secondary care interface.

Success stories

The following are examples of achievements by Collaborative sites:

Advanced access in dermatology

A third wave PCT has redesigned the care pathway for dermatology to include a GP specialist, and reduced delays from 36 weeks to four. After clearing the backlog, waiting times are maintained through management of capacity and demand on a weekly basis. Contingency plans are in place to increase capacity when demand rises.

 

´Physio Direct°

Since 1 November 2001, one PCT has been testing a self-referral physiotherapy service for patients registered with two of its practices. This covers a population of approximately 24000 patients. Patients can telephone and speak directly to a physiotherapist who will triage the problem. Same-day appointments are available for those patients who need to be seen. The service emails the patient