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Friday 28 October 2016
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What's your IQ?

Created by merging a series of legacy bodies the recently formed NHS IQ has been handed the task of nudging the health service towards large-scale transformational change. Management in Practice finds out how it intends to improve general practice

Keeping an eye out for innovative pilots running in the NHS across England, NHS Improving Quality (NHS IQ) teams swoop in with top experts to guide frontline managers and staff, then sweep out again, having learned from the experience, ready and raring to make improvements somewhere else.

After working with local authorities and a social research unit, health economist Steve Fairman joined the NHS, holding regional board-level positions before taking on the role of managing director at NHS IQ.

Describing himself as an “improvement-person” and not a clinician, Fairman explains: “We work with clinical associates. We have lots of GPs who work with us to front up the programmes, so that we look and feel like the people who [we’re working with]. Although I’m the head of the organisation, the way we operate – especially with primary care – is by working with GPs and practice managers that we’ve trained up in the quality improvement techniques and methods, and then they work with others.”

The histories, particular ways of working and partnerships inherited from the legacy bodies have come in useful as a baseline, but when speaking to Management in Practice, Fairman says it’s time to improve the focus on primary care. “It’s fairly new that we’re doing so much work in primary care,” Fairman says. “Evaluations of programmes we’re doing show that [GPs and practice managers] are getting a lot out of it. We’re starting to make a difference.”

The formation of NHS IQ and the focus on general practice could not have come at a better time. The harrowing report into care failings at Mid Staffordshire Hospital was released in February 2013, just four months before the body was established. This sparked a huge appetite for change in the NHS, which Improving Quality was perfectly poised to fill.

A flurry of reports into the future of general practice have been released by the leading bodies this year, calling for improved investment, better ways of working, more staff and more integration between primary and secondary care.

The subsequent increased media focus on the role of general practice
means that the organisation seems to have been way ahead its time with programmes such as Productive General Practice (PGP) and GP engagement with the five big killers.

PGP, the scheme which has been designed to help general practice continue to deliver high-quality care, is in a process of constant renewal, according to Fairman.

 The programme provides a framework for staff to take a “fresh look” at how the needs of patients are evolving, helping practices to develop services that improve patient experience, staff experience and productivity.

Early adopters of PGP said it required “enormous amounts” of commitment yet was quite slow to show results, Steve says. After work by the product development team, the scheme has been turned into something much more “dynamic and flexible”.

“It’s almost like a ‘PGP-lite,’” Steve adds. “There are now a number of really quick, practical, action-focused things that you can do. What we’ve done is focus on the commonly identified things that people find difficult in general practice. Our delivery partners – GPs and practice managers – provide the onsite support.”

More than 600 practices have started to implement PGP, and NHS IQ figures show that it’s starting to make an impact across a broad geographical area. According to Fairman the way PGP is used has similarities to the way that NHS IQ helps practices to develop schemes for the Prime Minister’s Challenge Fund, which has made £50 million available for general practices to expand access to patients. Many practices have clubbed together to develop 8am to 8pm opening, and NHS IQ has been there to offer support for 19 areas across the country.

“These Challenge Fund areas are doing it because they want to, not because someone is telling them to. They’ve all applied to take part in the programme because they feel that
they want to improve the access in their areas.

“We’re not pushing them, saying ‘You’ve got to open 8am to 8pm,’ they’re finding their own solutions. But we have people from each practice coming together once a month with our GPs and other improvement experts who will talk to them about specific techniques which address the problems they’re bringing from their own practices.”

Some practices are looking to improve the way prescriptions are run, or referrals. Some need help to be more efficient, or free up time, Fairman explains.

“Whatever it is, we can help them by bringing them really evidence-based improvement techniques and helping them to think about what they would do when they get back to their own practice,” he says.

On the day we spoke, NHS IQ had just started training the first cohort of quality improvement facilitators in London, starting with an intensive two-day session for practice level
staff drawn from across the Challenge Fund areas.

And the Five big killers project, which covers heart disease, stroke, cancer, lung and liver disease, aims to develop and test tools to improve the management of chronic disease.

NICE-aligned audit tools like the GRASP suite, which are used to prevent stroke, chronic obstructive pulmonary disease (COPD) and atrial fibrillation, are also currently in development by NHS IQ.

Each tool comes with a care management element, risk stratification tool and are compatible with GP systems. Up to 11,500 atrial fibrillation-related strokes - 3,200 of them fatal - could be avoided each year if every practice used the tools. But that doesn’t appear too far off - roughly 150 clinical commissioning groups and 2,500 practices across the UK are currently using them.

“This is a really important area for practice managers to be engaged in,” he says. “I think there are whole areas where it’s great to be working with GPs and have GPs working with us, but actually it’s really important to get management input as well.

“Because things like those audit tools, they’re perfect for the managers of the practice to use to help GPs really understand the risk profiles of their populations, about which patients ought to be seen more often who are maybe being missed.” Obvious benefits aside, Fairman believes these schemes could improve primary care in unexpected ways.

“I like to think we’re playing our part in making general practice an attractive place to work,” Fairman asserts.

“The practices that we’re working with can really see that they’re making a genuine impact on the five big killers. We’re giving them genuine tools to support and improve themselves, to become more productive and release time for the primary care team.”

The issues driving hundreds of practices to start an NHS IQ improvement programme, or to ask
for support for a pilot, are the same complaints that reverberate across
the UK.

“They say ‘We’re so busy; we can’t get our heads up to be able to get on and do the interesting stuff.’ We’re doing a lot of spreading and sharing of learning and innovation that we are learning from the practices that we are working with and we are then passing that to other practices.

“A lot of [the work we carry out] is around what we’d call getting on top of workload, freeing up time. We even see improvements in morale. One of the key things, too, is that a lot of the practices which are using PGP are making financial savings.”

Improving individual practices is good; making changes that can improve the entire system could be better. According to Fairman, NHS IQ is starting to look at general practice from a wider perspective, examining at how GP trainees can be supported during their final year of specialist training.

“We’ve been through a process of supporting some GP trainees in their final year of specialist training. We really immersed them in quality approaches and understanding the whole thing about in the context of life in a general practice today.

“We did some residential work and we’ve got unanimously positive feedback from that. They’re taking the learning back to their practices and really applying it.”

NHS IQ is now considering how to work with the Royal College of General Practice, Health Education England and Local Education and Training Boards to explore how such a programme could be carried out at scale. The passion that people working in general practice have for their work is massive, generally, Fairman says. “Sometimes it takes someone from outside to really help them to understand the amount of waste in their systems – in the nicest possible way.

“In terms of scheduling things better, understanding how to free up time, understanding demand and flow at different times. I know that practices know that, but some are on top of it and managing proactively in a way which helps them free up genuine clinical and managerial time.”