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‘Widespread’ variations in general practice quality

‘Widespread’ variations in general practice quality
25 March 2011

By Stuart Gidden

Widespread variation exists in the quality of general practice in England, and practices need to embrace radical change to keep pace with the “changing environment” of healthcare, according to a major new inquiry.

By Stuart Gidden

Widespread variation exists in the quality of general practice in England, and practices need to embrace radical change to keep pace with the “changing environment” of healthcare, according to a major new inquiry.

The independent think tank the King’s Fund praised the quality of general practice and its “international reputation for excellence”, but warned against complacency and highlighted areas for improvement in its report Improving the Quality of Care in General Practice, published today (24 March 2011).

The report highlighted significant variations in the rate of referrals, the quality of prescribing and the quality of diagnosis. It revealed an eight-fold variation in the rate at which practices urgently refer patients suspected of having cancer.

In addition, the inquiry raised concerns that continuity of care is worsening and that many patients are unable to see their preferred doctor. It also criticised a lack of care plans for patients with long-term conditions and said that unnecessary referrals cost the NHS hundreds of millions of pounds a year.

At the launch of the report, the inquiry’s chairman Sir Ian Kennedy, a former chair of the Healthcare Commission, described general practice as “the bedrock of the health service, but there is no room for complacency and there is room for improvement.”

The report calls for greater transparency over the performance of general practice, and urged practices to share quality data with patients, the public and other health professionals.

Sir Ian stressed one of the key messages of the report as “information, information, information.”

“While many practices have been at the vanguard of innovation and quality improvement, too many GPs remain unaware of significant variations and do not give priority to improving quality,” said Chris Ham, King’s Fund Chief Executive.

Jeremy Taylor, Chief Executive of National Voices, the organisation representing citizen interest in the NHS, welcomed the report and said that in contrast to the acute sector general practice had remained “relatively unscrutinised” in terms of performance data.

He said that greater transparency was “crucial” and that better quality data in the public domain would empower patients and assist greater citizen involvement in general practice “at all levels”.

Responding to the report, Dr Laurence Buckman, Chair of the British Medical Association’s GPs’ Committee, said: “We agree that GPs should be able to demonstrate the quality they offer to the public. However, as the report acknowledges, not all aspects of general practice work lend themselves to being measured easily.”

The King’s Fund report also calls for a “new deal for patients”, and said practices should involve patients much more closely in decisions about their care – “effective engagement with patients is fundamental to quality improvement”, it says.

“General practice must move from being the ‘gatekeeper’ of the system to being the ‘navigator’ of the system,” Sir Ian said. The inquiry report calls on GPs to play a greater role in co-ordinating care for people with complex needs, signposting patients to other public services and being held accountable for the quality of care received.

The report also calls on practices to “look beyond the surgery door” by taking a more active role in public health and tackling health inequalities, and reaching out to deprived communities.

However, in a question and answer session following the report launch, Dr Michelle Drage, Chief Executive of Londonwide Local Medical Committees, said the huge pressures faced by GPs meant delivering these recommendations would be a challenge.

“Does the report make any mention of the restrictions we [GPs] are under in terms of delivering quality?” she said.

One of the King’s Fund’s recommendations may give relief to GPs. The report advises accelerating the trend for practices to work as multidisciplinary teams, with GPs working closely with specialists and other professionals within and outside the practice.

It also recommends a shift from practices working in isolation towards ‘federated’ networks of practices working together.

But Dr Buckman said: “Increasingly practices are working more closely together, meaning they will be able to offer the wider range of services that patients expect.

“However, we should not assume that bigger always means better. Many patients value smaller practices and, as they consistently perform well clinically, it is important that this choice remains.”

Another key recommendation is that, as Sir Ian said, “practices need to adapt to the world around them” and embrace new technology and the increased expectations of patients.

“The infrastructure of primary care delivery has changed little over the past decades,” the report says, urging general practice to move away from being a “cottage industry” to delivering “post-industrial care”.

Dr Clare Gerada, Chair of the Royal College of GPs, said in response to the report: “GPs and their practice teams are working hard to deliver high-quality care, across a range of circumstances and we should take pride in the achievements of our profession.

“We must minimise unintended variation in quality, and make sure that patients get the best healthcare and services irrespective of where they live, or which clinician in a practice they might see.”

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