Despite being the envy of other nations, there are variations in the quality of general practice provision in England. A King’s Fund review aims to provide measures of performance that will improve services
If Lord Darzi’s review of the NHS in England achieved anything, it catapulted quality of care to the top of health policy. Some might regard it as odd that this was not already a priority — but that is because good clinical care was taken for granted. Not any more.
However, it is fair to say that the focus even now has mainly been on hospital services. Rather less attention has been paid to the quality of care within the community and general practice in particular.
This is despite the fact that GPs, nurses and other health care staff carry out almost 300 million general practice consultations a year — around 90% of all patient contact with the health service takes place in primary care.
It is clear then that if the NHS is to achieve the vision outlined in the Darzi review, general practice needs to be brought into the picture.
Already GPs are facing the prospect of greater scrutiny — all 8,500 practices in England will be required to register with the Care Quality Commission by 2011 and every family doctor will have to be relicensed and recertified every five years from 2010.
The expectations both of patients and those who commission services are also changing, not least in the demand for greater transparency and for information on the quality of services being provided.
Despite the introduction of the Quality and Outcomes Framework, which has provided incentives to general practice to improve the quality of patient care through pay-for-performance, there is little information to enable useful comparisons between the quality of care provided in different practices in some core areas.
What we do know about our general practice is that it is very well regarded and envied around the world. The universal and comprehensive care it provides is highly rated by patients.
But while there is some evidence that overall quality has improved in recent years, we also know that this has not been uniform. For core general practice activities such as diagnosing illness, referring patients to specialists and handing out prescriptions, there are significant variations in the standards of care patients receive.
Diagnosis is a critical skill and no practitioner can be expected to be right every time, but we need to know what good practice looks like. Poor diagnosis, especially of older people and those with complex chronic illnesses, is not uncommon.
And quality matters — recent research in Scotland showed that patients at higher risk of coronary heart disease tended to be linked to practices with lower-quality GP services and lower prescribing rates.
The quality of prescribing in general practice is vitally important: most GP consultations result in a prescription for drugs, there are increasing numbers of nurses who now prescribe, and pharmacists still provide direct supplies of medicines.
The King’s Fund has commissioned a major 18-month inquiry to address these issues. Our ambition is to help GPs and their teams, as well as the wider NHS, judge the quality of what is being provided in general practice.
The inquiry will examine a number of areas, including: access to care; the quality of diagnosis and referrals; and how people with long-term conditions are cared for. In each area we will examine what good quality care looks like, define the role of GPs and general practice in the provision of that care, and recommend how it should be measured. Importantly, we will try to establish how cost-effective care can be provided.
Our aim is to produce a range of measures that will calibrate the quality of care and should enable GPs, commissioners who buy their services and regulators to assess how well practices are doing and improve. Primarily, this will be about helping GPs and other practice staff lead the way in discussing how they measure the quality of care they provide.
We are committed to testing out our findings with clinical staff to make sure what we are saying is helpful and effective.
We very much hope this inquiry will make a significant contribution to helping the NHS improve the quality of general practice for patients and their families. General practice should be regarded with envy by other countries, but that does not mean there is no room for it to be even better.
Niall Dickson is chief executive of the King's Fund
