Lorraine Burey, a CLAHRC Greater Manchester Project Manager, blogs about how changes outside of our control had a big impact on our chronic kidney disease (CKD) projects – and how the team pushed on with the work anyway.
When I was asked to become involved in the CKD project in Central Manchester I was very excited, as I have a particular interest in CKD. It was also a tried and tested project that had been successfully implemented in Wigan Primary Care Trust (PCT), Salford PCT and Bolton PCT since 2009. To have the opportunity to roll-out the project across a whole clinical commissioning group (CCG), which had not been done before, was a challenge. In 2014 NHS Bury CCG became involved and we commenced the project in two of the CCG’s four sectors.
The recruitment for the first two phases in NHS Central Manchester CCG went smoothly and practices were enthusiastic and engaged. It was a similar situation in Bury and, initially, all of the practices in the two sectors agreed to take part in the project. However, in April 2015 changes to the CKD quality and outcomes framework (QOF) indicators were introduced, which had a significant impact on practice recruitment for the final phase of the Central Manchester project and continuing practice engagement in the Bury project, which was mid-way through. The QOF indicators that related to blood pressure management were retired and these had played an important role in attracting practices to the project and keeping them engaged. As there are competing priorities in primary care there was no longer the financial incentive for practices to prioritise CKD.
With CKD no longer being considered a priority we were unable to recruit all of the practices in the final phase of the NHS Central Manchester CCG project and a large number of practices in NHS Bury CCG withdrew from the project. The practices that we did work with in both CCGs were highly motivated and committed to the project and worked hard. In addition to the removal of the QOF indicators, in July 2014 the National Institute for Health and Care Excellence (NICE) released new CKD guidance and made substantial changes to how albumin/creatinine ratio (ACR) test results were interpreted and also to how CKD was coded. This created quite of lot of additional work for practices.
The CKD team learnt a lot about how to work with practices and keep them engaged when there was no financial incentive to complete the project. At the end of the project the project team met to reflect on what lessons we had learnt from our experiences. As far as recruitment was concerned, when first contacting practices we found that it was more effective to be brief but specifically tell them exactly what you want. It is also preferable to put everything in one email so you are not bombarding the practice manager with information. We found that being honest with staff and letting them know what was expected of them and explaining their role during the first meeting worked well so there was no confusion about responsibilities. Relationships need to be flexible and accommodating to the needs of each practice; for example, we had a practice manager who preferred to be telephoned rather than using email and a practice nurse who wanted a member of the team to sit and work with her when she was reviewing patient records on the practice system. The time taken to build effective relationships with members of the practice team makes it easier to engage with them in future.
The retirement of the CKD QOF indicators also had an impact on the data we collected for the final report – it was no longer there. We had to decide how we were going to collect this data, so our information analyst decided to write a MiQuest query to extract the data. This was a very positive aspect of the project as it meant we could decide what data we wanted to collect rather than being tied to what was collected for QOF. We could collect much more detailed data than previous projects and it also gave us access to other practices’ data who were no longer taking part in the project.
We also learnt a valuable lesson about putting crucial elements of the project under the control of other organisations. In NHS Bury CCG the installation of software that forms the basis of the project was completed by another organisation. We had issues with the length of time this was taking as practices could not start the project until this had been done. My advice would be to make sure, where you can, that you are in control of anything that could have a significant impact on your project.
The project team experienced a complete change of staff over a two month period. Potentially this could have had a negative effect on the project. However, the smaller project team worked very well together: meetings worked well, issues were resolved and problems overcome as a team. Setting deadlines for writing the report also worked well by making them specific and reviewing them regularly. We broke things down into small work packages using a stepped approach. The final proofreading and formatting of the report was done collaboratively by the project team. This worked much better than reviewing the report individually and it was quicker and easier to check the numbering of the contents page, figures and tables etc as a team.
With hard work from all the facilitators who supported practices over the four years of the project, CKD registers have increased by over 900 patients.
For more information about our CKD work in NHS Bury and Manchester CCGs, please contact Lorraine Burey, Project Manager.