Title: Measuring General Practice Productivity
Funder: Department of Health and Social Care

Abstract: There is a continuing need in the NHS to make the best use of resources available for the best possible outcomes. Despite most initial contacts happening within primary care, systems for measuring the performance of general practices are extremely limited, with the main mechanism for doing so (the quality and outcomes framework - QOF) criticised for being too narrow, with other indicators (ONS, NICE, CQC) similarly incomplete. Productivity in health care is defined as a ratio of outputs to inputs, adjusted for the quality of outputs based on measures such as patient satisfaction, waiting times etc. Despite considerable development of measures of productivity covering secondary care, measures for primary care remain at best crude or at worst absent. In this study we aim to develop and test a measure of primary care productivity that can be applied across all typical general practices (including their multidisciplinary teams) in England. We will do this using a procedure based on the well-tested ProMES methodology (Productivity Measurement and Enhancement System), in which the views and experience of general practice staff and patients will help determine the form of the measure, which will then be tested for its feasibility. This will result in a robust and valid measure, developed by practitioners and public that can be applied across GP practices more widely. The first stage will include ten workshops with practitioners and patients in 3 phases. Two large workshops in phase 1 will be used to explore what the key dimensions of effectiveness, productivity and quality are in general practice. In phase 2, six small workshops will explore different ways in which each could be measured, using existing data or otherwise. In phase 3 two large full-day workshops will consider the validity and relative strengths and weaknesses of the different measures identified, and how to weight the different dimensions so that an overall effectiveness measure can be constructed; this will then be converted to a productivity measure by dividing it by the input (expenditure of the practice). The resulting measure will then be put to a panel of experts, including representatives of NHS, regulatory, professional and patient bodies, to test its initial acceptability, and make adjustments if appropriate. We will then recruit 50 general practices to undertake a feasibility study of using the measure. Each practice will apply the measure using an online system over a minimum of six months, tracking its overall productivity on a monthly basis. Using a range of evaluation methods, including an online survey with practice managers, and telephone interviews with a range of practice managers, GPs, other practice staff and patient representatives, we will investigate the acceptability of the measure, the time and resources taken to gather and enter the data, and any difficulties encountered. Recommendations about use of the measure will be made based on this evaluation. The study will be supervised by a steering committee including representatives from NHS England, CQC, NICE, ONS, GPs, social care, and four PPI members. Participants (including GPs, other staff, and patients) will be recruited via a number of CCGs and locality managers who have agreed to participate in the project (to date six CCGs from different parts of England have expressed their willingness to participate).

Lay abstract: Primary care is a hugely important part of the NHS. General practitioners (GPs) and other staff in their practices provide the first point of care for the majority of patients, and continuing community-based care for many. Despite this, existing mechanisms for measuring the performance (effectiveness and productivity) of general practices are relatively crude and under-developed. The principal method is the Quality and Outcomes Framework (QOF), which is based around a series of indicators for a limited set of conditions that are readily measured or recorded. In order to maximise the benefit to patients and the public, productivity needs to be high, but at present this cannot be measured accurately, and it is difficult for patients and the public to know what quality standards they can expect from their GP and primary care. This study will aim to correct this by developing a measure of productivity that can be applied across most general practices. It will do this using the principle that the people who can best dictate what needs to be included in the measure are those who are closest to the matter at hand: GPs, other healthcare staff, patients and the public. The first stage of the project will consult with a wide variety of people from these groups using a series of workshops; these will be based around a method called the Productivity Measurement and Enhancement System (ProMES), which has been widely and successfully used in many sectors including healthcare. In these workshops a productivity measure will be constructed gradually by first identifying and agreeing the important dimensions of effectiveness, then exploring how these are best measured, and then by identifying the importance of each. After the productivity measure is developed, it will be tested in a feasibility study of 50 general practices. For at least six months staff in these practices will enter the necessary data into an online system which will map their own productivity on a monthly basis, testing out the ease of use. An online survey of practice managers, and a range of interviews with practice managers, GPs, other practice staff and patient representatives will evaluate the acceptability of the measure (including whether it is a fair reflection of the practice’s effectiveness), the time and resources taken to gather and enter the data, and any difficulties encountered. Recommendations about use of the measure will be made based on this evaluation. As well as the measure itself, a range of outputs will arise from the study, including summary reports for the participating practices, a final report setting out the findings and implications for policy makers and practitioners, practical guidance on implementing the measure for GP practices, CCGs and others to support them to implement the use of the measure in their practice, and various events and briefings for external audiences. Patient representatives will be involved in producing these outputs to ensure they can reach a public audience as well.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE