Engaging with Quality in Primary Care

Over 80 per cent of contact between the public and the health service takes place in primary care settings. However, as with other areas of healthcare, there is a gap between known best practice and everyday care. Through the Engaging with Quality in Primary Care scheme, clinicians from across the UK are getting involved in quality improvement projects in order to improve health outcomes for patients.

The rationale for involving clinicians in quality improvement projects is that the ultimate test for quality of care is what happens at the point of care for patients. Unless clinicians are fully engaged in efforts to improve quality the full potential of improvements will never be achieved.

The aims of the Engaging with Quality in Primary Care scheme are to:

• increase the capacity for clinical quality improvement in primary care
• engage primary care clinicians in clinical quality improvement
• enable primary care clinicians to contribute to the knowledge base on quality improvement
• use evidence from the projects to influence healthcare policy in ways that will embed clinical engagement in quality improvement in primary care.
  

The project teams we are supporting have all identified a gap between the current quality of clinical care and evidence of best practice. The teams are multi-professional and include patients or their representatives. The activities they will be involved in include:

• measuring the current quality of clinical care
• implementing activities to achieve improvements in clinical practice
• regularly monitoring changes in quality over time to assess the impact of their work
• sustaining change and sharing their learning with others.

The Engaging with Quality in Primary Care scheme supports clinical quality improvement projects in the following areas:

• improving the diagnosis of gastrointestinal disorders
  
• making healthcare more primary care led, patient centred and evidence based
• reducing inequalities in health and in how healthcare is delivered
  
• ensuring that people with back pain get the most appropriate care
• helping school nurses recognise and treat mental health problems
• improving services for women experiencing domestic violence
  
• improving the management of chronic kidney disease
  
• improving treatment options for people with insomnia.

For more information on the individual projects, see the following case studies.

The Leading Improvement Teams Programme

The Leading Improvement Teams Programme is a key part of the Engaging with Quality in Primary Care scheme. The Health Foundation has commissioned the Improvement Foundation to provide this programme, in order to support the project teams to be effective in meeting their project aims and the aims of the scheme more broadly. The programme will do this by:

• establishing a community of award holders who can exchange ideas with each other and share access to world experts in quality improvement
  
• enabling participants to benefit from leadership development, advice and providing constructive challenge from experts in quality improvement and leadership
  
• increasing the likelihood of a successful outcome for the projects, including their sustainability and spread beyond the life of The Health Foundation funding
  
• contributing to building capacity for quality improvement in the UK through enhancing the knowledge, competence and performance of participants.

Evaluating the scheme

The Health Foundation is passionate about evaluation. Our rigorous programme of evaluation enables us to assess the impact of our work objectively and to evaluate the effectiveness of our ideas for improving healthcare quality. All of our programmes are subject to external evaluation and, wherever possible, we commit to evaluating our work beyond the life of the funded period.

The evaluation of the Engaging with Quality in Primary Care scheme will be undertaken by RAND Europe and the Health Economics Research Group at the University of Brunel. It will be made up of two interrelated parts – self-evaluation and scheme level evaluation. Self-evaluation is an opportunity for the project teams to understand what difference their project has made locally and how successful they have been. The scheme level evaluation, meanwhile, will help The Health Foundation to understand whether the Engaging with Quality in Primary Care scheme has met our own objectives.

Building on our Engaging with Quality Initiative

The new Engaging with Quality in Primary Care scheme builds on the success of The Health Foundation’s earlier Engaging with Quality Initiative, which has been running since April 2005 and focuses on secondary care.

The Engaging with Quality Initiative is engaging healthcare professionals, through their professional bodies, to improve the quality of clinical care across the UK. Awards were made to Royal Colleges and other professional organisations to enable them to carry out nine clinical quality improvement projects, over a period of three to four years. The projects are addressing healthcare issues where there are gaps between current and best practice, as outlined either in national guidelines or those provided by specialist societies.

Nine projects are currently underway. These are working on the following areas:

• improving the quality of care for patients who self harm (Royal College of Psychiatrists)
  
• improving the care of adult patients undergoing elective surgery (Royal College of Nursing)
  
• improving the quality of prescribing for serious mental illness (Royal College of Psychiatrists)
  
• improving the assessment and management of perineal trauma in maternal care (Royal College of Midwives)
  
• improving the quality and effectiveness of hospital care for people with chronic obstructive pulmonary disease (Royal College of Physicians of London)
  
• improving the quality of care and outcomes from treatment for cancer of the bowel (Association of Coloproctologists of Great Britain and Ireland/Imperial College)
  
• assessing and improving the quality and management of care for patients with epilepsy (Royal College of Physicians of Edinburgh)
  
• assessing and improving the quality and management of care for patients with community-acquired pneumonia (Royal College of Physicians of Edinburgh)
  
• assessing and improving the quality of services for patients with inflammatory bowel disease (Royal College of Physicians of London).

i. A quality outcomes framework for gastrointestinal disorders

Around 10 per cent of work in general practice and hospital medicine is to do with digestive disorders. However, while the Quality and Outcomes Framework has targets for managing many chronic diseases, such as diabetes, heart disease and chronic pulmonary disease, there aren’t currently any equivalent criteria for good management for gastrointestinal problems.

This project aims to address this problem by developing guidelines for four gastrointestinal disorders. These are: reflux disease, which is an acid-related problem in the stomach and oesophagus; irritable bowel syndrome (IBS), which is unpleasant but not deadly; inflammatory bowel disease (IBD), which is rarer but more serious; and coeliac disease, a condition in which the patient cannot absorb certain foods.

“What we hope patients will get out of this will be slightly different for each condition,” project lead Professor Roger Jones comments. “For coeliac and IBD, we’re going to be focusing on improving diagnosis by making GPs more aware of the likely symptoms and the tests available to make a diagnosis. We also want to ensure that patients have access to secondary care advice, such as nutritionists and specialists in gastroenterology, which can lead to better outcomes.”

“For reflux disease, we want to make sure that GPs understand what the condition is and that the diagnosis can be made without necessarily doing an endoscopy,” he continues. “We want to clarify some of the relationships between reflux disease and things like chest pain and asthma, which are not very well understood in general practice.”

“In the case of IBS, it seems that GPs are okay at making the diagnosis but often only after doing lots of tests,” Roger says. “That’s got implications both for using resources and in terms of giving patients a mixed message about the seriousness of their condition.”

A key focus for the team is to ensure that guidelines for these conditions incorporate the patient perspective. The first phase of the study will therefore run a series of focus groups with the National Association for Crohn’s and Colitis, Coeliac UK and the IBS Network to find out what patients think represents good quality care. The second phase will be a review of existing evidence and guidance, and the third will be to synthesise the current guidance with the new findings on patients’ requirements. “For each of the conditions, we’ll then pick up to four achievable changes that we would like to make to improve patient care,” Roger says.

If the project is successful, the team hopes to see their work incorporated into a future Quality and Outcomes Framework on gastrointestinal disorders. “We’re already in discussion with the people responsible for doing the QOF,” Roger reveals. “We want to make sure that it incorporates the findings from our patient work.”

The team also plans to develop computer generated prompts to remind GPs about particular steps that they ought to be taking to better manage patient care. Finally, they hope to use their findings to influence practice-based commissioning.

“In the future, if a cluster of practices is interested in improving the care of one of those four conditions, we might be able to say: ‘you shouldn’t be buying 100 endoscopies, because you don’t need them, but you should be buying a day a week of cognitive behavioural therapy’,” Roger suggests. “In other words, we hope that the findings that we come up with towards the end of the project will inform future practice-based commissioning for services for gastrointestinal disorders.”

Lead organisation: CORE: The Digestive Disorders Foundation
Partners: King’s College, University of London, National Association for Crohn’s and Colitis, Coeliac UK, Irritable Bowel Syndrome Network, Primary Care Society for Gastroenterology, British Society of Gastroenterology, University of Oxford

Contact
Professor Roger Jones
roger.jones@kcl.ac.uk

ii. A whole system approach to quality improvement

In 1999 the Government published the NHS Plan which aimed to make the health service more patient centred. Recent policy documents have built on this ambition and set out plans to move healthcare services out of hospitals into primary care and for GPs to become more involved in commissioning services.

This project will be looking at ways of developing practice-based commissioning that ensure it is primary care led, patient centred and evidence based. “Put simply, the aim of our project is to improve on each of these three aspects, which are lacking in the NHS at present, in order to improve the quality of care for patients,” project lead Dr Nicholas Hicks says.

The project team will start by working with the Patients’ Forum and GP practices across Milton Keynes to identify areas for improvement. The list of potential areas includes diabetes mellitus, chronic obstructive pulmonary disease and asthma, cardiovascular disease, terminal care, depression, reducing inappropriate attendance at Accident and Emergency departments and management of suspected deep vein thrombosis. The project may also look at communication between GPs and consultants.

Local librarians and the Centre for Evidence Based Medicine at Oxford University will then work with the Patients’ Forum and the GP practices to understand the evidence base in the different areas. This will include educational techniques to help them refine their questions and to make decisions about how services could be redesigned.

“In each of the areas where change is required, we will develop tailored change management programme based on an assessment of the current barriers and opportunities,” Nicholas continues. “There will be evaluation techniques so we can tell if the individual changes have made a difference. This will include patients’ views.”

Individual practices across Milton Keynes will lead on different clinical areas and spread their improvement to all of the GP practices involved in the project. The team hopes that this collaborative approach will lead to larger scale changes than would otherwise be possible.

By the end of the project, Nicholas wants to see quantifiable improvements in the quality of care. However, he adds: “Just as important will be changes in the way of working. The approaches that have led to those changes will be embedded across the health community and the public will be involved every step of the way.”

Nicholas also hopes that the project will create a lasting system which allows people to make change happen. “People can have lots of good ideas, but most of them founder and they are rarely big and sustainable,” he says. “If we can create a system in which people know how it works and they can actually see that their ideas lead to change, that would be a huge success.”

Project lead: Milton Keynes Primary Care Trust
Partners: Milton Keynes Practice Based Commissioning Collaborative, University of Oxford, Department of Primary Health Care and Centre for Evidence Based Medicine, Milton Keynes Patient Forum

Contact:
Dr Nicholas Hicks
nicholas.hicks@mkpct.nhs.uk

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iii. Equity, ethnicity and expert patients

Encompassing all the GP practices in Tower Hamlets, this project aims to reduce inequalities in how healthcare is delivered and ultimately in the health of the population. The team plan to do this in two ways: first, by supporting GPs to identify and understand inequality in their practice and to provide a better and more equitable service. Secondly, the team intends to work with professionals and patients to develop self management programmes and to improve the public’s awareness of their right of access to healthcare services.

There is a real urgency to this project. Although Tower Hamlets has a young, transient and diverse population, health is poor and the borough ranks as one of the most deprived communities in the UK. The low life expectancy in Tower Hamlets means that it comes within the Government’s ‘spearhead’ areas with a target to reduce health inequalities by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth.

The project team have chosen to focus on the three disease areas which contribute most to poor health in Tower Hamlets. These are diabetes, cardiovascular disease and chronic obstructive pulmonary disease (COPD).

“Our project will look at each of these disease areas in order to identify where the inequity lies,” Dr Sally Hull, one of the project leads, says. “For example, the incidence of Type 2 diabetes in the area is twice the national average, and coronary heart disease is 50 per cent higher. In the case of local men of Bangladeshi origin, it is almost double the national rate. COPD also has a very high prevalence in Tower Hamlets, even compared to surrounding localities.”

Dr John Robson, who works alongside Sally, adds: “We are going to hold a mirror up and show how individual practices are performing in relation to their peers. Each practice will be given an equity report detailing their performance by age, sex and by ethnic group for the different disease areas.”

To develop this ‘mirror’, the project team will collect baseline data from GP practices. They will compare service provision both across the borough and against national guidelines. The team will then work with the practices to analyse the data and seek to understand how to improve their services. The methods will include education, facilitated support within practices and using IT systems to support case management.

Working with patient groups, the team will also develop a package of measures to help patients work in partnership with their GPs to manage their own condition more effectively.

Dr Kambiz Boomla, the third lead on the project, hopes that this will address the low expectations that some people in Tower Hamlets have about their health. “What we have to challenge is that sense of pessimism and lack of control – the ‘I’m going to die anyway’ attitude,” he says. “We want patients to access the services which are there for them and to change those services so that access becomes easier and more appropriate.”

The team hopes that this project will help those people most at risk of COPD, heart disease and diabetes in Tower Hamlets to access the right services and to receive appropriate treatment. Ultimately, they expect this to minimise the effect of these diseases in the long term and to improve life expectancy in the borough.

Lead organisation: Improving Management in Gastroenterology (IMAGE)
Partners: Tower Hamlets Primary Care Trust, Social Action for Health, City University London

Contact
Dr John Robson j.robson@qmul.ac.uk

iv. Implementing evidence based primary care for back pain

Four out of five people will experience back pain at some point in the lives. For some people it will be a chronic debilitating problem which affects their ability to work, socialise and have a family life. Back pain is also costly for society. The charity BackCare has estimated that nearly 5 million working days per year are lost through bad backs. Back pain also accounts for around 10 per cent of GPs’ appointments and costs the NHS around £1 billion.

This project aims to improve the care of people with back pain by training GPs and physiotherapists in how to identify which treatment is most appropriate for different types of patients and how to deliver that treatment. It is being run by the North Staffordshire and Cheshire Primary Care Research and Development Consortium, led by Keele University.

Professor Elaine Hay, the project lead, explains: “We know that people with pain and disability will respond to various manual techniques of physiotherapy and we know that people with psychological distress may need a cognitive psychological approach. However, what practitioners don’t know at the moment is how to decide who should get which treatment. So we’ve worked out a way of dividing patients into three types and have developed programmes to train physiotherapists to deliver different interventions for each group.”

The project team will implement this technique in GP practices and community physiotherapy centres in the Central and East Cheshire Primary Care Trust. Their main way of doing this will be through a patient questionnaire. “One of the challenges in the project is to see how best to incorporate the questionnaire within routine general practice,” Elaine says.

The project will also train physiotherapists to deliver the different types of intervention. “We want to see if we can change physiotherapists’ behaviour in the way they work,” Elaine continues. “We know that changing clinicians’ behaviour is really tricky because people tend to practice as they have been trained, not according to the best available evidence.”

The project team is planning a series of practice based meetings, where they will train staff in the use of the questionnaire and in using different prompts to ensure high uptake. This team will also undertake an initial baseline data collection prior to the training, which will be followed by further data collection to measure the difference the project has made.

Elaine emphasises that the focus will be on outcomes that patients regard as important. “Ideally, when someone goes to see their GP with back pain, they would fill in a questionnaire and then this would be followed by another questionnaire at various outcome points to measure whether they have improved,” she says. “We ask patients what an important goal is for them and then measure whether or not they have achieved that.”

In terms of spreading the learning from the project, Elaine hopes that the physiotherapy interventions the team has developed may be incorporated into accredited post-graduate training. “We want to try and influence policy through input in to the National Institute for Clinical Excellence low back pain guidelines and through the Department of Health strategies,” she adds.

Lead organisation: Keele University
Partners: The Primary Care Musculoskeletal Research Centre, Central and East Cheshire Primary Care Trust

Contact
Professor Elaine Hay
e.m.hay@cphc.keele.ac.uk

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v. Improving the management of back pain

As with ‘Implementing evidence based primary care for back pain’, this project aims to improve the care of people with back pain. The team aims to give GP practices the skills to better manage the treatment of patients with back pain.

“We have become aware that treating back pain is inconsistent across primary care,” project lead Dr Charles Campion Smith says. “I think there have been problems in applying evidence from studies to an individual person in front of you with needs and expectations. There are also some knowledge gaps and what we might call myths about using pain relief in back care.”

The project team will work with ten practices across two Primary Care Trusts. “We are going to ask the practice teams to rate their confidence and skills and get them to share their stories using a narrative approach to learning about patients,” Charles explains. “We are also going to gather patient stories, both about what went well and what they would have liked to have been different.”

The team also plan to do some detailed survey work in the practices to look at how the project impacts on patient care.

The project will be tailored to the learning needs of the individual practices and will provide them with specific information about current research and explore and expose myths around pain relief for back care. “We are also going to give them clues about how to spot people who are presenting with back pain because of other distresses in their life,” Charles says. “We will help the practices become more skilled at recognising this and give them strategies of how to respond, including referral for cognitive behavioural therapy where needed.”

The team will work with the practices in small groups using an action learning set approach. These will be inter-professional and patients will be invited to join the groups. The team is also planning to link up with local expert patients groups.

At the end of the project, the team hopes the practices will have greater confidence in working with patients to manage back pain. “We hope that when a patient comes in and says ‘it’s my back Doc’, the GP won’t say ‘oh no’. Instead the GP will say ‘oh good’, because he or she has some clear pathways and ways of managing it.” Charles adds.

The team also hopes that learning from their work may apply in other clinical areas. “I think the tendency is for practices to be so focussed on the topic that they’re not aware of the methodology they used. So we are hoping to get them to reflect on the techniques they’ve used to achieve the improvement in back pain and then to think about whether it could be useful in other clinical areas,” Charles concludes.

Lead organisation: Bournemouth University
Partners: BackCare, South Wiltshire Health and Social Care Academy, Severn Wessex Deanery, Bournemouth and Poole and South Wiltshire Primary Care Trusts

Contact
Dr Charles Campion Smith
charlescs@metronet.co.uk

vi. Improving the quality of mental health in schools

According to Rethink, between 10 and 20 per cent of children and young people have a mental health problem, some of whom will have a severe mental illness. School nurses have a pivotal role in spotting mental health problems in adolescents but at present are under-trained in mental health work. This project aims to provide them with training and support in learning how to recognise and treat mental health problems at school.

“School nurses are often isolated and scattered, thinly spread over as many as ten schools,” project lead Professor Andre Tylee from the Institute of Psychiatry, King’s College London says. “Yet we know that a significant proportion of young people will have mental health problems and that when they do, they don’t come to general practice or primary care for help. We need to be able to spot that they’re having problems earlier in the place where they’re at most, which is at school.”

Drawing on the expertise of two members of the project team, who are school nurses at Sutton and Merton, the team aims to do two things. The first is to train school nurses to be better at recognising and assessing mental health problems, to know when to refer people for help and to manage children’s mental health themselves. This will involve collating existing training material and developing new tools, including video-based learning. “It’s not just a question of referring everybody, it’s actually about them feeling skilled to work with young people,” Andre says.

Secondly, the team wants to develop more support systems for school nurses as a professional group. “This would include networks of peer support, so they can meet together, learn together and discuss children that they’ve seen as well,” Andre says.

The team’s approach is multi-disciplinary. Andre himself has a GP background but there are also two school nurses, a child psychiatrist, a young patient and a carer on the project team. The study coordinator is Mr Mark Haddad, a nurse researcher at the Institute of Psychiatry, working with a project lead from Rethink.

If the pilot project is successful, young people with mental health problems will get spotted much earlier and receive effective treatment. “This will help them in several ways,” Andre explains. “It will help their quality of life, their attainment at school, their health in general and their emotional well being.”

In order to make the project sustainable, the team is working with existing school nurse networks in London and the southeast of England, including the Royal College of Nursing. “We hope that when we’ve packed our bags and gone in three years’ time there’ll be an active network of school nurses who have an interest in sharing their experiences in mental health and who will work and learn together,” Andre concludes.

Lead organisation: Institute of Psychiatry, King’s College London Partners: Charlie Waller Memorial Trust, Community Practitioners and Health Visitors Association, Rethink, Royal College of Nursing, Sutton and Merton Primary Care Trust

Contact
Professor Andre Tylee
a.tylee@iop.kcl.ac.uk

vii. Primary care domestic violence programme

Domestic violence is any physical, sexual or psychological abuse that takes place within an intimate relationship and that forms a pattern of coercive and controlling behaviour. The British Crime Survey in 2004 found that 13 per cent of women experienced domestic violence, sexual victimisation or stalking in the past year. This rises to 45 per cent lifetime prevalence. Domestic violence damages women’s physical and mental health and has long term health and educational consequences for their children.

This project aims to tackle the mismatch between the large public health problem presented by domestic violence and the poor response from the NHS in general, and from primary care in particular. “We haven’t yet found a way of responding appropriately and providing a quality service in relation to partner violence,” project lead Professor Gene Feder says. “Women experiencing violence often want to disclose this to healthcare professionals they trust, yet primary care services have lagged behind other agencies in identifying women at risk and developing effective support.”

The team is setting up a randomised control trial to test an educational and support programme for GP practices, which aims to help them identify and refer patients who are experiencing domestic violence. “A key aspect is the partnership with voluntary agencies, which are providing most of the expertise for women experiencing domestic violence,” Gene says.

The trial name is Identification and Referral to Improve Safety (IRIS). Iris was a messenger for the Greek Gods, symbolised by the rainbow and carrying a herald’s staff. This prefigures the universal symbol of healing: a rod with two intertwined snakes.

The new approach is being trialled in Bristol and east London, but if it is successful the team hopes it will be taken up as a model in other primary care trusts. Ultimately, it could be used to commission services nationally and to inform the general practice Quality and Outcomes Framework.

“Our goal is to develop a robust model for training practices to improve identification and to access expert domestic violence services,” Gene continues. “If successful, we will have a good case for an NHS investment in domestic violence training for primary care. We also want to provide a basis for the commissioning of expertise from the voluntary organisations that, at the moment, are run on a shoestring.

“At the end of three years, we hope to have good evidence that we can make a difference in terms of identification and referral, as well as outcomes for women taking up referral to domestic violence advocacy,” he concludes.

Lead organisation: Queen Mary, University of London
Partners: London South Bank University, Bristol University, The Nia project, Bristol NextLink, Bristol Primary Care Trust and City and Hackney Primary Care Trust

Contact
Professor Gene Feder
g.s.feder@qmul.ac.uk

viii. Quality improvement in chronic kidney disease

The role of the kidneys is to remove waste products and extra fluid from the bloodstream. They also help control blood pressure and stimulate the production of red blood cells. In the case of patients with chronic kidney disease, waste products remain in their blood and they can be prone to anaemia, cardiovascular disease, renal failure and ultimately death. However, there are many things that GPs and patients can do to slow down the process.

This project aims to help GPs in southwest London and Surrey better identify and manage patients with the condition. “Chronic kidney disease is a clinical problem that’s been around for years,” project clinical lead Dr Simon de Lusignan says. “What’s new is that we now have is a much more effective way of flagging up patients whose kidney function is declining, called estimated glomerular filtration rate, and a new quality target for people with chronic kidney disease was introduced with the Qualities and Outcomes Framework last year.”

Once the patients have been identified, the next step is to control their blood pressure, which slows the rate of decline of kidney function. “This could delay when people might need to go onto dialysis or transplantation,” Simon explains. “In the case of elderly patients, it can delay decline in their kidney function until this ceases to be their top health problem. This means they never actually need to go on to suffer the symptoms of kidney failure and avoid the need for dialysis and transplantation.”

“Other things GPs can do include looking at the medication patients are on to see if they are taking anything that impairs kidney function but isn’t essential for their care; and also check men for signs of prostate disease,” Simon adds.

To tackle the problem, the team are looking at three different quality improvement techniques. These techniques will be run in separate practices, while a fourth practice will be measured without any intervention to provide a baseline comparison.

Firstly, a patient empowerment programme will try to increase patients’ understanding of the disease and its implications for their lifestyle. Secondly, audit based education will be used to feed back data to groups of practices about their quality of care, with a local clinical champion presenting comparative data in an educational context. Thirdly, the team will work with a practice looking to offer new ways of looking after people with chronic kidney disease.

“To try and ensure the findings can be generalised, we’re planning to run this in eight areas: four in the North of England and four in the South,” Simon says. “We’ll also try to pair up inner city and suburban practices, so that we get a mixture of types of practices in each intervention.”

“The problem is linking cause and effect when you do this, which is one of the big challenges in quality improvement research,” he continues. “We’re planning to address this by collecting data at multiple points and looking to link changes to the dates of interventions.”

If the project is successful, the team hopes to interest Primary Care Trust commissioning teams in their findings. “If the lessons for this are going to be shared, then the critical people are commissioners in the eight different areas this study will cover,” Simon explains. “The biggest challenge is getting the methodology right so we can ascribe change to interventions in a way that will convince the commissioners that these are the strands of quality improvement that are really worth embedding in the NHS in the medium to long term.”

Lead organisations: St George’s, University of London and Kidney Research UK
Partners: Renal Association, Royal College of General Practitioners

Contacts
Dr Simon de Lusignan
slusigna@sgul.ac.uk
Michael Nation
michaelnation@kidneyresearchuk.org

ix. Resources for effective sleep treatment

Everyone has difficulty sleeping at some point in their life but in most cases this is short term. However, around one in ten people suffer chronic insomnia, which occurs on a regular basis or over a long period of time. It is most commonly caused by stress and worry but can also be triggered by pain, noise, medication, depression and shift-work. Insomnia contributes to daytime tiredness, which in turn can lead to accidents, illness and work and relationship problems.

This project aims to improve treatment for people with insomnia by promoting a range of treatment options beyond sleeping pills, which are not always the most appropriate course of action and carry the risk of side effects and addiction.

“We’ve surveyed about 800 patients and 40 practices in Lincolnshire, focussing on patients who’d had a repeat prescription of sleeping tablets in the previous six months,” project lead Professor Niroshan Siriwardena of the West Lincolnshire Primary Care Trust explains. “Nine out of ten patients were on a repeat prescription that had been started by their GP. About two thirds took it every night, which is not a good thing to do because of addiction, and half had side effects like headache, dizziness and nausea. One fifth of the patients wanted to stop their tablets and at least half of the patients said they’d tried to come off treatment.”

“We also surveyed practitioners who had beliefs about drug treatments that tended to promote prescribing of newer, more expensive sleeping tablets contrary to the evidence,” he continues. “But they also had some good ideas on how to improve the situation.”

The project is trying to discourage GPs from prescribing sleeping pills as a first line response, and to encourage them to explore other treatment options first, which may be more in line with what patients actually need. “We also want to find ways of helping people who have been on sleeping pills for some time but would prefer not to be,” Niro adds.

Some of the alternative treatments available include sleep hygiene and sleep restriction. “Sleep hygiene is really a bundle of things which aim to regulate sleep patterns,” Niro says. “It includes avoiding things like caffeine, alcohol, exercise and eating late in the evening. Sleep restriction means initially going to sleep later to ensure good quality sleep, making sure you wake up at the same time every day, which is better for your body clock, and then gradually moving back your time to go to sleep.”

For the next phase of the project, the team is planning to work with patients to understand what they need from a consultation for insomnia and to work with a number of practices and primary care teams to test the impact of different approaches. “There are some specific interventions that we know work for those who have been on long term sleeping tablets, like writing to patients, review consultations with GPs, self help booklets and, in some cases, psychological therapies,” Niro says. “But there may be other things that practices can do to avoid starting drug treatment in the first place and to improve people’s experiences of insomnia management.”

The team intends to present data back to practices and to analyse whether prescribing is changing as a result of their new approach. If specific measures or combinations of measures are successful in the first five or ten pilot areas, they plan to use opinion leaders to spread the changes and learning more widely. They also hope to link with commissioners in the county and to develop learning materials with the Centre for Health Improvement in Leadership in Lincolnshire.

Lead organisation: West Lincolnshire Primary Care Trust
Partners: East Midlands Mental Health Research Network Hub, Lincolnshire and Nottinghamshire Mental Health Trusts, Lincoln and Nottingham Universities, Trent Research and Development Support Unit.

Contact
Professor Niroshan Siriwardena
nsiriwardena@lincoln.ac.uk