Prof Becky Malby, Nick Downham, Tony Hufflett
Performance metrics for Primary Care are not fit for purpose. Ive previously shared how GPAD data on patient satisfaction shows no correlation to numbers of appointments, but thats all the NHS measures. Numbers of face to face and telephone appointments tell us nothing about quality or how patients needs are met. What matters to both patients, carers and clinicians is usually continuity and meeting needs. Thats never measured. This is what we think general practices and PCNs should be measuring to ‘temperature’ test their effectiveness and impact.
Is your Practice and your PCN working as well as it can? How do you know? What could you do?
Measures that Matter is an introduction to the sort of metrics that help practices and PCNs review, reflect on their effectiveness in terms of their intent (purpose) and to work out what they need to do to make their work even better
Measures are a feedback loop – they help you work out how well you are doing and think about what you could do differently. If you want to make things better you need to know whats working and whats not working and for that you need data.
Start with Purpose
You are looking at your measures to tell you how you are doing in relation to your purpose. Often PCNs and Practices aren’t clear what their purpose is. Here is my view:
General Practice’s role is to universally and fairly improve the health outcomes of the practice population (individuals and families), meet needs as close to home as possible and act as the gatekeeper to the rest of the NHS. In doing so general practice is careful about how it uses its resources, collaborates where it needs help, and makes sure that those working in the practice have fulfilling roles, and work as an effective team. (Madan et al 2017, Pratt & Rowland 2018, Malby 2019)1
PCN’s role is to universally and fairly support people with complex needs that can’t be managed by the resources in general practice on their own, to help member practices be the best they can be, and to collaborate with communities and other sectors to help people live well at home. (Malby 2019)
What to Measure in General Practice
The diagram below sets out 5 categories of measures and some examples of what you could measure. The value in deciding what you measure is in the discussion to agree one or two key metrics for each, and then reviewing them over time (how are they changing) and between practices (how are other practices doing and what can you learn from each other).
Each category relates to the purpose described above.
Each metric suggested is a benchmarking metric you can use to test the temperature of your practice in terms of how well you are doing, what you might need to pay attention too.
- Outcomes and Quality – we find the annual patient satisfaction data is a really good indicator of quality. What would you need as a benchmark measure for health outcomes? We have suggested a metric on diabetes or hypertension.
- Health Inequalities – if practices are to provide services universally and fairly then how do you know you are? We suggest 3 measures here based on what we have seen in our work in general practice. If you are doing well on these 3 areas, you are probably doing well in terms of being fair in how you provide your general practice services.
- Complex needs – the evidence is well known; people with complex needs need continuity. Providing continuity also improves staff satisfaction (Fraser & Clarke 2023). Are you proactively providing continuity to cohorts of your patients that have complex needs? They also need you to be well connected too the assets in your community – what measure might you use to know if you are making the most of these assets?
- Staff morale – there is a direct correlation between staff morale and quality and outcomes, and your ability to function as a business. Are you measuring these key indicators regularly and discussing how to improve them? Note there is a direct link between providing continuity for people with complex needs and GP satisfaction with their job.
- Future Proofing – is your practice financially robust and are you satisfied you have the staff you need now and in the future?
Taking all these together and measuring them regularly gives you patterns and trends, which you can use to adapt how you organise your work and develop your services and your relationship with others (other practices in your PCN, or other organisations)
What to Measure as a PCN
The following diagram sets out 3 categories of measures and some examples of what you could measure. The value is in agreeing a few key metrics for each, and then reviewing them over time (how are they changing) and exploring these with local PCNs to see how are others are doing and what can you learn from each other)
Each category relates to the purpose described above.
Each metric suggested as an example is a benchmarking metric you can use to test the temperature of your PCN in terms of how well you are doing, what you might need to pay attention too.
- Complex Needs and Health Inequalities – are you providing MDTs/ ARRS to meet a known need rather than an assumed need? Develop measures that demonstrate the impact of your ARRS roles. If you are clear what needs the ARRS are meeting you can determine metrics for these. Fairness in screening across all your member practices can indicate how your practices are viewing their role in reducing inequalities
- Robust Member Practices – if your practices are not robust then you cannot work collaboratively together. As a PCN you are supporting practices to be the best they can be so you need to know (a) are they funded fairly (b) do they have the staff they need and is that equitable across your member practices (c) how satisfied are patients with your member practices? If patients are not satisfied its an indicator the practice is not working as well as it could.
- Taking an Asset Based Approach – PCNs as collaborations of practices are well placed to make the most of working with communities and partners organisations (VCSE/ schools) to work upstream to meet needs early on, and to help support people who need help to live a good life.
Taking all these together and measuring them regularly gives you patterns and trends, which you can use to adapt how you organise your work and develop your services and your relationship with others (for instance what you need in terms of ARRS roles)
Here is a video that sets all of this out in more detail
Resources
Much of the work that underpins the ideas in this blog are set out in the following report Malby et al (2023) Universal Healthcare National Inquiry Report, London South Bank University.
You can find more on continuity here:
There are loads of resources on our Primary Care Network Academy Website
References
Madan, A., Manek, N. and Gregory, S., (2017). General practice: the heart of the NHS. British Journal of General Practice, 67(657), pp.150-151.
Pratt, J. and Rowland, M., (2018). Practitioners and practices: a conflict of values?. CRC Press.
Malby, B. (2019) Primary Care Networks – The purpose matters. Learning Journeys Blog. Accessed at https://beckymalby.wordpress.com/2019/03/22/primary-care-networks-the-purpose-matters/
- Note the RCGP approach is to describe the work of General practice rather than identify what General practice is for (what its there to do) ↩︎
Becky Malby 