Pushing on a closed door? When improvement work slips off the agenda

Jelly beans in a kidney-shaped bowl.

A personal perspective from NIHR CLAHRC GM’s, Project Manager, John Humphreys

A kidney care programme has been an ever present feature at CLAHRC Greater Manchester (GM), even prior to when I joined the team all the way back in 2010. I’ve been involved in, or on the periphery of, a series of projects within this programme focused on improving the detection and management of chronic kidney disease (CKD). So it’s with a degree of sadness that the manifestation of contextual changes in the NHS has made it no longer viable as a piece of improvement work that we can offer.

The projects (running 2009 2016) embedded better care processes for patients with CKD once diagnosed (e.g. awareness of the diagnosis / identification of proteinuria / better blood pressure control) thereby reducing their risk of adverse events. There were always significant barriers to overcome such as clinical scepticism of CKD; confidence gaps in how to manage it; and concerns that increasing the number of diagnoses would result in proportionate rises in referrals to secondary care. Most of these obstacles were overcome through facilitated discussions within practices.

However, all work has its shelf life – and a sequence of nationwide changes means the project no longer mirrors the priorities of local stakeholders. The delivery model that we used was modified with each iteration to reflect the resource available. The initial model in 2009 was a more intensive approach aligned to an improvement science model, which was modified into more streamlined models. These models were less resource intensive, but were supplemented by tools developed through preceding projects. One thing that we learned early on was that success was heavily influenced by each practice taking some ownership of the project – and the facilitator engaging them on a journey where they could each see recognisable changes in how they were identifying and caring for patients with CKD.

The structural re-organisation of healthcare in 2012/3 set in motion a one-way direction of travel for the fate of this work. Although I was much less involved at this point, it was obvious that engagement with primary care had become a much more challenging. One member of a local clinical commissioning group (CCG) told me after the reform, “just getting the time to sit down with them [GPs] to explain what the project is going to be is the bit where you get a closed door, because there is no time to do it. It really is that busy out there.” Simultaneously, I witnessed my colleagues repeatedly needing to attempt more conciliatory approaches to delivery in an environment where the enthusiasm for ‘nice-to-do’ work had plummeted to near drought. The drain on resource capacity limited interest to practices where alternative resources could be identified within their practices (e.g. medical students / practice nurses) to take on the work involved – but this now rarely involved GPs permanently based at the practices.

We held a consultation exercise with GPs and CCG representatives across GM in mid-2015 to investigate local operational and strategic priorities for kidney care – with the hope of creating work that would appeal to local needs. Our findings (reported here) suggested that priorities were being heavily driven by national policy – and that meant kidney health did not feature prominently on their radars. Where people did consider it important there were few consistencies in what they felt would be effective as support. A common theme, however, was that clinicians were only going to be receptive to additional improvement projects that required no-to-little input time from them. This was consistent with the reports from my colleagues still trying to deliver the CKD projects.

Just prior to our consultation exercise two further changes occurred which ultimately closed the door on this piece of work:

  • New NICE guidelines had been released for diagnosing and managing CKD. Our consultation told us that awareness around this was highly variable and only reinforced existing research evidence that without a structured supporting process, clinical guidelines are unlikely to be implemented.
  • It was confirmed that three of the four CKD indicators within the Quality and Outcomes Framework (QOF) were being retired. You can read more about what those changes were in an accompanying blog. The assumption made in the accompanying justification was that people would continue pre-existing care activities as routine practice now they were established. Our consultation evidence told us this was a completely unrealistic expectation.

The effect was that the updated guidelines added a new layer of complexity to the projects already being delivered and required increased practice resource, precisely at a time when the financial incentive for localities to focus on this as an area of care was immediately removed[1]. Our consultation work told us that, far from being perceived as a mechanism of control over clinical activity, primary care staff, generally, regretted the loss of the QOF CKD indicators. Having data and prompts on their clinical systems helped them to ensure that patients were receiving at least a basic level of attention to their CKD diagnosis each year. The majority viewpoint was that retirement of these indicators sent out the wrong message to clinicians that actually this was no longer regarded as an important area of care amongst policy makers at national level.

That message resonated at local level for CCGs defining their priority areas of care. As new issues were added to the agenda, allocating time and resources to improvement work without incentivisation attached (directly or indirectly) continued to descend in importance. It’s easy to understand why in a context of high resource demand and competing priorities that clinicians are less likely to act on an area which will not be recognised politically or through remuneration for their activities. However, the consequence was that full-time was called on a long-standing piece of work we’d delivered.


[1] A blog on the effect of the AKI CQUIN retirement in secondary care can be read here.