Summary of the impact

Research conducted at the University of Manchester (UoM) has shaped the design of national systems of accreditation for general practice in the UK, Europe and beyond. Accreditation systems set standards that reflect key aspects of the organisational systems and processes in general practice that are needed to ensure delivery of good quality care. Accreditation systems also provide a kite mark of quality assurance and act as a platform for supporting continuous quality improvement. UoM developed indicators of quality in general practice structure and organisation and demonstrated how they could be used effectively to improve quality. Working in partnership with health professional organisations, governmental organisations and other universities, UoM used knowledge from the research to develop systems for general practice accreditation now used in the UK and across Europe.

Underpinning research

See numbered references in section 3.

The impact is based on research that took place at UoM from 1995 to date, with the first major publication in 1998. The key researchers were:

• Stephen Campbell (Professor of Primary Care Research, 1993-date)
• Helen Lester (Professor of Primary Care, 2006-2011)
• Martin Marshall (Professor of General Practice, 2000-2006)
• Martin Roland (Professor of General Practice, 1992-2009)

The work was conducted by the National Primary Care Research and Development Centre (NPCRDC), a Department of Health funded policy research unit based in UoM. The programme of research initiated in 1995 (i) developed measures of quality of care in general practice, (ii) described and explained variations in quality and (iii) developed and tested interventions to improve the quality of care. The programme is underpinned by a conceptual definition of quality of care which showed that quality measurement must address clinical excellence (e.g. adherence to clinical care standards) as well as patient experience, underpinned by sound organisational systems and processes for driving quality improvement (1).

This case study describes the impact of research relating to measures of organisational quality. Separate case studies in this UoA describe the impact of research relating to measures of patient experience and clinical excellence.

Governments need to have accreditation systems in place to ensure that healthcare provider organisations meet desired standards of care quality and safety. This requires the development of care quality standards and measures that can be applied efficiently to assess whether an organisation has the necessary organisational systems and processes in place to deliver safe and effective care. NPCRDC developed innovative methods to design and test indicators of quality in the organisational systems and processes within general practice that underpin care quality and safety (2).

In collaboration with the Universities of Nijmegen and Heidelberg, NPCRDC applied these methods to the development of a European Practice Assessment accreditation scheme suitable for use by general practices across Europe (3,4). The research was funded by the Bertelsmann Foundation. The European Practice Assessment accreditation scheme won the 2009 award of the European Health Forum Gastein. This award, widely regarded as the 'European Oscar' for healthcare, is given for major innovations in European healthcare. Subsequent research demonstrated the effectiveness of practice accreditation as a method for driving quality improvement in primary care (5).

In the UK, NPCRDC worked in partnership with the Royal College of General Practitioners (RCGP), applying knowledge from the research to the development of a British system of Practice Accreditation (6). The development work was undertaken in close collaboration with the General Medical Council, Royal College of Nursing, Care Quality Commission, Department of Health, NHS Confederation Primary Care Trusts and patient groups to ensure the Practice Accreditation scheme was aligned to the priorities and concerns of other key stakeholders.

References to the research

Details of the impact

See numbered corroborating sources (S) in section 5.

The European Practice Assessment (EPA) scheme has been used by 1,584 practices (1,170 primary care practices) across 7 countries: Germany, Switzerland, Austria, Belgium, Greece, Romania, Slovenia. The scheme and the indicators are available in the following languages: English, Dutch, French, German, Romanian, Slovenian, Greek, Arab and Hebrew. Overall, 507 practices have used the EPA scheme (S1).

In 2005 the German federal government introduced a regulation which stipulated that all healthcare providers, including general practices, are obliged to implement an annual quality management programme in order to demonstrate compliance with national systems for accountability in healthcare provision. The European Practice Accreditation scheme, designed by NPCRDC with its European partners is one federally approved option for demonstrating compliance in general practice (S2). Implementation was supported by our partners in the University of Heidelberg and the Institute for Applied Quality Improvement and Research in Health Care (AQUA-Institute) in Gottingen. In total 303 primary care practices have used EPA in Germany. 103 of these German general practices used the European Practice Accreditation scheme twice, to measure longitudinal changes in quality improvement over the period 2008-date (S2). Practices showed an overall 10% increase in scores across the domain "Quality & safety" including "complaint management" (30% increase), "critical incident analysis" (10%) and "quality procedures and policies" (15%).

The methods used to develop the European Practice Assessment for general practice have been applied by the AQUA-Institute to develop a European Practice Assessment scheme for dental healthcare provision in Germany (S3,S4). From 2008, 187 dental healthcare organisations have used the EPA-Dental scheme to assess their quality of care (63 having used it twice). Compared with the comparative group at first assessment, the intervention group at second assessment had significantly better scores for the domains "infrastructure" (Intervention group 94.2%, Comparative group 84.0%) and "quality and safety" (Intervention group 88.7%, Comparative group 78.1%).

In the UK, the General Practice Accreditation scheme developed by the Royal College of General Practitioners in partnership with NPCRDC was implemented in July 2011 and closed to new applicants in February 2013 (S5,S6). Upon successful completion, Practice Accreditation is valid for three years. From 2011, 260 of the 8,088 general practices in England have sought accreditation of which 4 have been successful with the remainder ongoing. The scheme consists of six domains with the 78 standards, 42 of which are mapped to processes, protocols and systems that specifically support the requirements of CQC registration. The fulfilment of the RCGP Practice Accreditation scheme will enable practices to demonstrate compliance with the registration requirements of the Care Quality Commission (CQC) which, from April 2013, is responsible for quality of assurance of English primary care.

The Irish College of General Practitioners have built on the EPA and RCGP accreditation schemes to develop their own national scheme, and informed European-wide discussions on accreditation as led by EQUIP-WONCA (S7).

Sources to corroborate the impact

S1. http://www.epa-qm.de/epa/front_content.php?idart=218

S2. Letter from AQUA Institute in Göttingen (J Szecenyi) which used a modified version of the indicator development process as part of the Federal Government work.

S3. Götz K, Szecsenyi J, Broge B, Willms S. Welche Wirkung hat Qualitätsmanagement in Arztpraxen? Ergebnisse aus Entwicklung und Evaluation des Europäischen Praxisassessments (EPA). Aqua-Verlag, Göttingen, 2011

S4. Qualitätsmanagement-Systeme für die Zahnarztpraxis. Informationsdienst des Instituts der Deutschen Zahnärzte (IDZ), Köln, 2005 (ISSN 0931-9816)

S5. http://www.rcgp-practiceaccreditation.org.uk/CustomPages/CustomPage.aspx?id=17

S6. Letter from RCGP detailing recruitment to practice accreditation scheme.

S7. http://www.topaseurope.eu/?q=node/3 for WONCA-EQUIP which notes role of NPCRDC.