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Primary Care’s Documents | Achieving Clinical Excellence (ACE) in Primary Care

Some years ago I was approached by a group of local GPs who wanted to apply for CCG support for an improvement idea.  They wanted to improve the flow of their elderly (>70 years) patients through the unscheduled care stream of our local acute hospital.  And they recognised that they needed to develop their improvement skills to do it.  So started the ACE project and what we learned was surprising, and delighting and alarming. My job was improvement science coach – they did the hard work.

What they showed was that by re-designing some of their primary care processes, they could have a big impact on the experience and outcomes of elderly patients admitted as emergencies.

And what they learned was how to do this in a scientific, logical, rational and enjoyable way using a tried-and-tested framework called HCSE (health care systems engineering).

And they wrote up their story and published it (attached), and kept doing what they had demonstrated had worked for their patients and themselves.

Recently they approached me again to assist with evaluating the longer-term evidence, and I was very happy to help because I too was curious to learn if their improvements had sustained. They had.

This is the acid test of any effective improvement method:
(a) can it be learned and applied by the people who live the process and
(b) are there significant improvements on all dimensions – safety, flow, quality and value-4-money and
(c) are the improvements self-sustaining.

And it appears that the HCSE approach works just as well in primary care as it does in secondary care.

The next BIG challenge is Primary Care Access … i.e. eliminating the chaos and stress associated with delivering the highest footfall service in the NHS with 1,000,000 appointments per day in England.

The good news is that it looks like this “wicked problem” is also amenable to the improvement-by-design approach but only if the people who own the process i.e. GPs, practice nurses, receptionists and practice managers learn how to do it themselves.

So that is my question … is there anyone in the Q Community Primary Care SIG who is willing to have a go?

Discussion (2)

  1. Thanks for sharing this, Simon.
    I have recently made a start on this wicked problem in my own Practice; it’s small -scale (14,000 patients), with potential to scale up across the Primary Care cluster,once lessons learned.
    We are only three weeks in.
    I couldnt agree more that it starts, and ends, with front-line staff engagement. Already had some good ideas from Reception staff, who are at the sharp end of the problem.
    I would stress the importance of patient input: I have engaged a representative from our Patient Participation group on the improvement team, so the improvements are truly co-produced.

  2. Hi Sue,

    Great to hear that you have got stuck in and involved all the circle-of-control stakeholders in the conversation from the start including patients, and have started from their perspective. It can be a bit humbling to do that and the trap is to jump to solutions before establishing a diagnosis.

    I was working with a primary care team last year who wanted to improve their booking system (the plan is to have a centralised one eventually). So, one thing I asked them to do was to step into the shoes of a patient and phone their own practice at 08:00 and try to book a same-day appointment. After that frustrating experience they had a bit of an “oh dear” when I pointed out that 1000 of their patients per week were having exactly that experience – and >99% do not complaining – possibly because it has been like that for so long that they just accept it as inevitable.

    It is not inevitable. It is the direct consequence of the design of the system and it is avoidable.

    Not surprisingly, the primary care team didn’t believe that it was possible for them to improve it themselves until I demonstrated how to do it in practice. Then they had a big “ah ha” and took off like a rocket.

    So, if you do get stuck please don’t give up … just phone-a-friend … that is part of the co-production philosophy … learning from each other.

    And I’d love to hear how you get on. Will you post updates?

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