All together now?

Published: 14/11/2002, Volume II2, No. 5813 Page 2 3 4

Like any programme of change, the national primary care collaborative still has its sceptics. But the guiding spirit behind the enterprise, GP Dr John Oldham, believes the results speak for themselves. He talks to Alastair McLellan

The National Primary Care Development Team can boast many successes, including a 60 per cent-plus reduction in waiting time for GPs and dramatic cuts in deaths from coronary heart disease. But there is one significant measure of success, which is much less likely to grab the headlines. And That is particularly surprising in the context of an NHS workforce crying out for the centre to reduce its incessant demands for information - voluntary form-filling.

The first GP practices to join NPDT's collaborative network last attended a workshop 18 months ago.

Those who join the collaborative have to supply data on how well they are performing - this is important not only to check progress, but to identify best practice. The practices in the first wave have now been told that they can stop sending information. But the data returns continue to arrive every month - practices still want to know how their record measures up, still want to continue to contribute to the work of the collaborative.

The man who has, together with his small team, engendered such enthusiasm among hundreds of practices is Glossop GP Dr John Oldham. Quietly spoken, but with a reputation for getting his own way, Dr Oldham still does patient consultations a couple a days of week.

It was at his practice that he first started examining how continuous qualityimprovement methods more commonly applied in industry could benefit primary care. A business school dissertation on the subject led to speaking engagements and finally to an introduction to Dr Don Berwick, president of the American Institute for Healthcare Improvement, and the man whose ideas underpin much of the modernisation efforts sweeping through the NHS.

Dr Berwick invited Dr Oldham to the US to contribute to IHI's work on spreading best practice through the use of collaboratives (see box opposite).

Dr Oldham's work, and his exposure to what IHI was doing in the US, convinced him that 'clinicians are not sole arbiters of care' and that 'unless the system in which they work is operating effectively, they will never deliver the best care'. He felt that GPs needed to understand 'processes', whether relatively straightforward systems such as those used for booking GP appointments or the complex pathways between primary and secondary care - and how to change them if necessary.

Only then could they make sensible decisions on annual planning, strategy and practice structure - and as a result serve patients better.

Already a part-time adviser to the primary care division of the Department of Health, when Labour came to power, Dr Oldham was asked to set up a team to deliver a national collaborative programme.

Work began in June 2000, with access, coronary heart disease and pathways between primary and secondary care chosen as the test beds for the impact of quality improvement. These areas were primarily chosen, says Dr Oldham, because they were, and are, very important to patients and clinicians. He adds that the collaborative's access goals pre-dated the government's 48-hour consultation target.

NPDT had no influence on the first practices to join the collaborative - they were nominated by the participating primary care trusts. Dr Oldham can now look back on those early workshops with rueful detachment. 'We had every range of attitude from enthusiasm to downright hostility. Some of the early orientation meetings were real tin hats and flak jacket jobs.'

Over two years later, Dr Oldham is secure in the knowledge that every wave of the collaborative has delivered results faster than the previous one because learning has been successfully passed on from one stage to the next.

He stresses that this success is the result of a 'team effort' between NPDT, local project managers, primary care trusts and practices.

He also claims that the results vindicate NPDT's 'strategic intent to create capacity and capability in quality improvement methods in primary care organisations' through the use of a collaborative.

According to Dr Oldham, the initiative had been developed and launched in the knowledge that its successful delivery 'necessitated creating sustainability by maximising resources to the field, using participants as teachers, having a programme of individual development, and creating centres in early sites which would learn how to operate local versions of the national collaborative'.

However, despite NPDT's record, Dr Oldham still expects many practices to be anxious about joining the collaborative but claims that one of the reasons for its success is that its methods reduce anxiety about change in the minds of GPs and practice managers.

'There will be people who found joining the collaborative really worked for them and others who are still not quite there. I am very relaxed about that, because I know ultimately they will see how relevant it is to them locally.'

NPDT is now part of the Modernisation Agency. Dr Oldham acknowledges that it is another branch of the agency - the national primary and care trust development programme - which is largely responsible for developing PCTs as organisations, but believes NPDT is making that development easier.

He argues that the collaborative has created a way to capture the entrepreneurial spirit in GPs and use it to the benefit of the whole health economy, as well as guarding against the disengagement which many doctors feel toward the reform process.

On a purely practical front, having more people who understand how to map processes, how to sequence implementation of change and who are tied into bestpractice networks should be a real boon to developing PCTs.

He also hopes the regional NPDT centres will be a knowledge resource for all involved in improving services.

In the area of primary care commissioning of secondary care services, NPDT has created a network of PCT and strategic health authority chief executives 'to tell us what is going to be wanted by them'.

Nationally, Dr Oldham says his team's links with, for example, those developing diagnostic and treatment centres in Sweden or US health management organisations, helps tie the NHS into international best practice.

He believes the collaborative has the ability to get primary and secondary clinicians working together in a way which characterised the best fundholding or commissioning group arrangements. But he admits that this has been the most difficult part of its work.

More attention, he says, should have been paid to creating relationships across the divide. But now NPDT has 11 regional centres and 80 project managers from the first waves of the collaborative to call on, this is much easier.

Patients who have benefited from new ways of working are also powerful advocates, he points out. As an example of the improvements achieved, he tells a story of an acute trust which told one of the PCTs involved in the collaborative that it needed another breast surgeon.

'What's the critical point in your pathway?' asked the PCT. 'What?' replied the acute trust. The NPDT project manager analysed the problem and concluded that the problem was in radiology.

'So they got a radiologist instead, ' grins Dr Oldham.

The NHS being what it is, few programmes with the impact of the primary care collaborative are free of criticism. One of the most common complaints levelled at NPDT is that it constitutes empire building by Dr Oldham and consumes more than its fair share of resources.

Dr Oldham points out that his team of 24 represents just 4 per cent of the Modernisation Agency's workforce and that its annual budget of£13.5m, compares with an overall agency budget of£111.1m.

Dr Oldham claims: 'I am not in the business of sucking people out of the NHS to create large central teams. I was under some substantive pressure to run waves five, six etc at a national level, but I said I wanted it done locally.'

Another criticism is that NPDT is so determined to plough its own furrow that it does not integrate well with other modernisation programmes.

Dr Oldham says the NPDT attempts to ensure that relevant modernisation programmes, such as those looking at booked admissions or cataract operations are involved in workshops. However, he does admit that having a small team sometimes makes it hard to attend every meeting. NPDT's director of partnerships instead attempts to keep track of the latest plans and policies emerging from the Department of Health and elsewhere.

'In one sense, I am apologetic about that [not attending meetings] but in others I am not, ' says Dr Oldham. 'The NHS has suffered from chronic initiative-itis. Our overall goal has always been to transfer skills into the field.'

He is not surprised that what he claims are attempts to avoid being diverted from his mission are sometimes mistaken for highhandedness.

The lack of external evaluation of the collaboratives' work is the final barb chucked in its direction. NPDT says that because the global measures it uses are tracked by all participants in the same way, the programme is effectively 'self-evaluating'.

With the day-to-day work of the collaborative increasingly taking place at a local level, the national team is looking for the next challenge. It has already begun work on developing a healthy communities collaborative.

This will attempt to engage communities in tackling a particular health issue. One of the aims is to see whether doing so will give people the confidence to tackle other problems.

NPDT is also looking at ways to reduce falls by the elderly and is working with the national institute for mental health to spread best practice on dealing with depression.

Whatever the exact outcome of this future work, Dr Oldham's crusade to teach medics 'things they never get taught in medical school' seems set to continue - with the DoH currently funding NPDT to the tune of£6m a year. Managers can expect to enjoy the unique experience of receiving earnest talks from GPs and other primary care workers on the importance of process improvement and doing 'today's work today' for some time to come.

Making waves: how the collaborative works

The primary care collaborative is the 'vehicle' used by the National Primary Care Development Team to spread improvement 'quickly and effectively'. The work of the collaborative originally focused on three areas: access to primary care, coronary heart disease and the way in which better patient pathways between primary and secondary care can improve capacity and demand management.

Evidence suggested that 20 per cent of the primary care system needed to be converted to the quality improvement cause to create the necessary momentum for change throughout England. As a result, the collaborative was initially developed in four national waves, each involving 20 primary care trusts selected by NPDT.

The final waves of the programme are to be delivered through 11 regional centres each covering approximately three strategic health authority areas. The centres will be run by those who took part in the first four waves of the collaborative.

By late summer 2002, 1,200 practices of all types, serving 11 million patients, had joined the collaborative. By the end of the year, every PCT in England should have been offered the opportunity to take part, with 2,500 practices already on board.

The collaborative approach takes as one of its starting points the view that in a large system 'somebody somewhere' will have solved most problems, and that one of the secrets to improving services is creating a structure which can be used to spread good ideas.

A PCT initially puts forward a number of practices to join the collaborative. These practices send teams to attend a series of three, two-day workshops. The teams can and do consist of GPs, nurses, practice managers and patients.

Periods between the workshops are used to further refine plans, implement learning and measure success. Later workshops are used to demonstrate how those attending have succeeded in making change.

Improvement is achieved through 'small rapid cycles of change', commonly known as 'plan, do, study, act cycles'. Dedicated project managers facilitate the changes and coach the practice teams.

The practices are then charged with spreading expertise among others within the PCT - with NPDT continuing to provide support in the form of workshops.

The aim is not only to improve the quality of systems and services, but also to enable participants to develop quality improvement skills which can be employed elsewhere.

During the first four waves, each contributing practice received£5,000 to, for example, cover staff attendance at workshops. Participating PCTs received£30,000 to support the appointment of the project manager and, in the second year of the programme, another£25,000 to extend learning throughout the trust.

PCTs can and do provide some upfront funding to compensate practices for the necessary cover during workshops and other development work. However, there is concern that in some PCTs these funds - as with so many other allocations - are being diverted to service deficits or some other more pressing target.

Finally, NPDT is in the process of providing funding for an access facilitator for every PCT. These people will be trained and accredited by the national team, but based within their local NPDT centre.