Quality in Primary Care Open Access

The Primary Care Quality Group is an integral part of Ashton Leigh and Wigan Primary Care Trust (PCT). It forms part of the Directorate of Quality and Professional Leadership and works closely with the 62 general practitioner (GP) practices in the Wigan Borough.

In 1990 the Conservative Government introduced many changes to healthcare in the country. One area that was almost universally welcomed by the profession was audit. This became compulsory in secondary care and has remained voluntary in primary care. Wigan Medical Audit Advisory Group (MAAG), which was composed of several GPs, a manager and two audit facilitators, became a cohesive group very quickly, and the initial years were spent going into practices, teaching about audit, and gaining the confidence of the primary healthcare teams. This confidence was then built on, and the audit side was developed, by implementing an audit assistant scheme, which encourages each practice to have an audit assistant. The scheme provides a grant to cover two hours per month on audit activity, plus attendance at two training/support sessions per annum. The practices also welcomed and supported the guidelines that were developed to aid them. Medicine is not isolated to hospital or general practice, and guidelines were developed jointly with secondary care and public health. These shared plans helped to break down old barriers and fostered relationships, which have been invaluable for the benefit of patient care. The guidelines were not just sent out to practices; many hours were spent by the MAAG team in education, either at lectures (raising awareness) or in small groups. The MAAG became known as the Primary Care Audit Group (PCAG) and expanded its role, by developing new systems and encompassing chronic disease into its remit.

The use of disease registers was recognised as an excellent tool for audits, and with this in mind the Diabetes Register was developed as a joint venture between primary and secondary care. It registers the diabetes patients in the Wigan district, and is a shared care register covering all patients receiving diabetes care in hospital, general practice or both. The register provides an annual recall system to ensure that patients are invited for an annual review. Compre-hensive audit reports can be produced for individual practices, primary care group (PCG) areas and for the district as a whole.

Following the success of the Diabetes Register, the Coronary Heart Disease (CHD) Risk Factor Register was set up in 1993. Coronary heart disease is the major cause of premature death in Britain, with Wigan having one of the worst records in the country. The minimum dataset was decided by GPs who identified what information they considered to be important, and what could realistically be collected in an opportunistic way. Lengthy negotia-tions also took place with local cardiologists and the Lipid Screening Department and Health Promotion, to ensure that the data collected fulfilled the needs of all parties. The register was designed to produce district-wide, ward-based data on the prevalence of risk factors for heart disease and, as patients were re-screened, to monitor improvements over time. In 1997 an ischaemic heart disease (IHD) project worker was appointed by the group to establish and encourage annual reviews, a call and recall system and to develop audit packages. The register was superseded in 1998 by the IHD Register, which was piloted over three sites, Wigan and Bolton, Bury and Rochdale and Salford and Trafford Health Author-ities. The register was then further developed, by encouraging more practices onto the scheme, and the Wigan Borough IHD Steering Group was established to develop heart disease guidelines. The group included members of the PCAG, cardiologists, coronary specialist nurses, pathologists and public health workers. The guidelines produced were: heart failure, hyperlipidaemia, myocardial infarction and angina.

In 1999 clinical governance was a newly intro-duced term, yet most of the processes had been taking place to a variable degree over the preceding years. Each of the PCGs in Ashton Leigh and Wigan recognised that the PCAG had addressed most of this work, and they therefore agreed to work jointly in supporting quality improvements in primary care. The Ashton Leigh and Wigan Primary Care Quality Group was formed from the PCAG with the remit to coordinate clinical governance across the three PCGs, and membership included the Quality Group coordinator – a local GP, three clinical governance leads (one from each PCG) who were all local GPs, the GP tutor for the Wigan Borough, the practice nurse development manager and the pharmaceutical advisor.

Audit was only one part of quality, and practices needed education and training support on a variety of topics. The remit of the Quality Group is now a whole systems approach and clinical guidelines that are developed by the PCT, which have an impact on primary care, come to the group for ratification.

The group is supported by five non-medical staff, who, in their separate functions, support and develop practices: the chronic disease management project worker, education facilitator, clinical governance facilitator, IHD Register support worker and clerical o¤cer. The staff work very closely as a team, and are supported by the Quality Group coordinator and clinical advisor who meet with them once a week to discuss any problems, and assist in moving forward. The current team have been together for 12 months, building on the work of the past and setting new objectives. They have had to cope with staff vacancies, a restructuring exercise and a change of address, but have come through positively and are looking forward to new challenges.

As each National Service Framework (NSF) was introduced the group produced a summary for practices, outlining the headings and simplifying the processes. These were well received by practices that didn’t have the time to read through the large documents detailing the NSFs.

The group has also produced a series of guides, on the seven aspects of clinical governance that were introduced to practices through a series of workshops held in each PCG area. These were commended by the Commission for Health Improvement (CHI) when they visited Wigan Borough in 2000, and they suggested that the group shares the documents in the wider context. In December 2002 the chronic disease management project worker and the clinical govern-ance facilitator hosted a stand at the National Institute of Clinical Excellence (NICE) conference in Birmingham, demonstrating the guides. Many PCTs were interested and have received copies, and the group is in the process of formulating an evaluation form to assess how the guides have been used and how effective they have been. The guides give a brief but comprehensive explanation of the heading, how practices can achieve the targets and a table of who should be involved and their individual roles. The topics are listed below:

• clinical governance

• audit

• significant event auditing

• risk management

• evidence-based medicine

• personal development plans

• involving patients and the public.

The chronic disease management project worker has facilitated the development of diabetes and mental health guidelines in consultation with primary and secondary care, and these are to be distributed to practices in the near future.

A further development by the chronic disease management project worker in conjunction with a local GP with an interest in technology has been the development of a CD-ROM – the Primary Care Lexicon. This is a clinical governance research tool for GPs, nurses and practice staff, including clinical guidelines’ web links and referral forms for secondary care. This is to be distributed to practices in the spring. A CD has been chosen rather than a web page, to enable all the practice to access it without slowing down their medical systems.

Along with the development of the Quality Group, the emergence of clinical governance and the CHD National Service Framework, the Wigan Borough IHD Register was enhanced. A total of 61 out of 62 practices are now involved in the project across Ashton, Leigh and Wigan locality health groups (LHGs). The chronic disease management project worker has responsibility for the IHD Register and regularly visits practices offering them support and guidance. Many reports can now be provided for practices that will help to demonstrate achievement of the NSF audit criteria and can also identify those patients who are not reaching the desired targets. In 2001 the Heart Disease Guidelines were revised by the IHD Steering Group and re-issued to practices through a series of workshops, detailing the changes.

Twelve months ago an education facilitator was appointed to the Quality Group, to advise practices on protected learning time and establishing clinical governance priorities. The postgraduate education allowance (PGEA) system allows GPs to apply for PGEA approval for education activities within the practice, or for developing individual learning plans, or for prolonged study leave to set up clinical governance systems. Education activities may include meetings about Clinical Governance, and meetings leading to the development of a practice professional development plan (PPDP). The GP tutor felt that there was a need for protected time for practice-based education and the PCT has resourced these hours. The practice education facilitator visits practices on a regular basis to encourage GPs to produce personal development plans (PDPs) as part of the continuing professional development process. Practices are also being encouraged to produce PPDPs as part of this process, which outlines the priorities chosen for the coming year. From the visits, the education facilitator can assess the training needs of practices, and plans are under way to develop training via pharmaceutical companies. The practice education facilitator also helps practices to achieve the targets set by the LHGs in the Practice Education Scheme, which is funded by the PCT and allows practices to choose a range of educational developments that they would like to undertake in the year.

Audit remains a strong point within the group, and the clinical governance facilitator runs the Audit Assistant Scheme. The scheme is as it was originally devised, but consideration is now being given to including pharmaceutical audits with a revised cash incentive. To this end the clinical governance facilitator is working with the head of medicines management to review the scheme. Seventy-five percent of practices now have an audit assistant and the bi-annual review meetings have been an excellent opportunity for assistants to meet together and share experiences. The speakers at the meetings recently, have discussed issues such as diabetes, the older person’s NSF and asthma.

The Quality Group newsletter Quest is produced on a quarterly basis by the clinical governance facilitator and is distributed to practices within the Wigan Borough. This includes items, which the group wants to bring to the attention of practice staff, and has been further developed and rolled out to the PCT as a whole, to use as an information-sharing forum.

Another strong link in the group is the practice nurse development manager. She has been respons-ible for developing three practice nurse training practices across the borough, one for each LHG area. The training practices provide a practice nurse induction programme, cytology training practice placements, local training events for practice nurses, and practice placements for BSc practice nurse students and P2000 students, and shadowing arrangements for other nursing disciplines. Training practices are monitored by the practice nurse development manager with regular trainers’ meetings and an activity record and evaluation by nurses attending the training practice. Training needs analysis has been undertaken by the practice nurse development manager and a database established. A practice nurse core training programme to address training needs, is currently underway.

The Quality Group also has links with the Patient Advice and Liaison Service (PALS), risk management and the complaints department via their link with the director of quality, and has developed a good working relationship with these services. A workshop for GPs, practice nurses and practice managers was held earlier this year to promote these departments, and a representative from each gave a talk on their roles and how they could help practices.

The Quality Group wants to further develop its services by appointing three data quality facilitators who will work with practices to streamline their practice IT systems. The chronic disease management project worker has been working with other PCTs to develop the Quality Group’s strategy and we have yet to appoint to these roles. We are also looking at creating links with the opticians, dentists and pharmacists in the borough and are in the process of making our guides more generic.

The Primary Care Quality Group is proud of its relationship with the practices of the borough and aims to further develop important areas of clinical governance, and to raise the understanding of the processes necessary to underpin quality improve-ment in primary care.