status quo of quo vadis? - KCE

52 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76
Many GPs reported more interest in the quality development of their practice after the
EPA visit. However, they also reported that the instrument, in its present form, did not
entirely fit the Belgian reality of general practice and the single-handed practices in
particular. Still many Dutch and German GPs also work solo and apply the EPA tool.
However their practices do employ personnel.
The application of EPA in Belgium would require an adaptation. Some questions were
not applicable (i.e. using written material instead of electronic sources for patient
information) whilst other ones were not included (i.e. concerning home visits).
Finally, the participant GPs considered a large-scale implementation during the focus
groups. They suggested an implementation on a voluntary basis resulting in anonymous
data that could allow the benchmarking of their practice with other practices.
3.5 CONCLUSION: EPA PROJECT
EPA addresses the organisation and the management of the practice. This pilot project
aimed to study the feasibility of the European Practice Assessment tool in a sample of
voluntary GPs.
This pilot project encountered serious difficulties for attracting participating GPs. One
reason could be that the Belgian GPs did not clearly perceive their potential win in this
experience: they are not familiar with the culture and concepts of quality improvement.
Possibly considering a general practice as a business (as in Australia), needing adequate
data input for its management, is not yet common sense in Belgium.
The small sample size of this study, with selection biases, hampers the extension of the
findings to the population of Belgian GPs. Our participants appreciated the opportunity
to go through the EPA process. They laid emphasis on the necessary adaptation to the
Belgian context and requested more coaching for implementing changes in the practice.
The implementation of EPA requires that the practices would be able to run the quality
cycle work, from the data collection to the feedback and change implementation. This
capacity encompasses a culture of openness and safety for receiving feedback and
creating plans for quality development. Dedicated time for the quality improvement is
needed. This type of quality activity is currently not financed. In its present form, EPA
like projects are hard to organise for GPs working in a single-handed practices.
Some GPs suggest a role for LOKS/GLEMS. They could be involved in the recruitment
of practices and for the discussion after the procedure. Confidentiality of data is of
major importance.
To date, only limited data exist on the way GPs change behaviour while using the EPA
instrument 138 . The limited results among Belgian participants showed little change. This
finding shows the need for subsequent contacts with the visitor in a more than one
cycle project.
Offering EPA-like instruments to GPs is a complex and expensive task. Its large-scale
implementation requires a significant facilitating and organisational structure. In the
Netherlands, the total cost for a 3-year project using an EPA-like instrument is
estimated around 2000 euros per GP per year (about 1 euro per patient per year).
This study did not focus on clinical indicators. This domain however, becomes more
prominent in foreign systems as in the Netherlands and Australia whilst it is of central
importance in the UK. A practice based approach may easily encompass the careful
introduction of clinical indicators when adequate IT infrastructure and coaching are
available.
The cost-effectiveness of the procedure is a central issue. The outcome of introducing
practice based evaluation can possibly lead to
• A culture of quality development among GPs,
• New roles for LOKs and GLEMs,
• Introduction of target payments for the indicators that are included,