Senior Fellow, Health Policy
Nick works as Senior Fellow at the King’s Fund and is the project director of the 18-month independent Inquiry into the Quality of General Practice in England. Nick’s varied work portfolio includes research and analysis on commissioning, primary care, integrated care, long-term conditions management and the role of new assistive technologies
It is a radical and unsettling time for those working in the NHS. If the new coalition government sticks to the plans set out in the white paper Equity and Excellence, then strategic health authorities and primary care trusts (PCTs) will be phased out, the NHS will be given new leadership in the form of the independent NHS Commissioning Board, and responsibility for the £80bn budget that comes with this will be devolved to GP commissioners.
At the heart of these changes is a radical new future for general practice. Real budgets will be transferred to GP commissioning organisations. These will work as new statutory organisations with an “accountable officer”, and they will be responsible for commissioning services for all patients registered to groups of practices that comprise their membership (plus those in this catchment that are not registered).
Significantly, changes will be sought to GP contracts that will make it compulsory for them to take up membership of a GP commissioning consortium as a condition of practice. The plans will also place GPs in leading roles with these commissioning consortia and so GPs will take responsibility for challenging member practices to raise their standards in meeting quality and financial targets.
Those practices that succeed will enjoy the benefits of income through a “quality premium”, whose payment will be related to the performance of the commissioning consortium as a whole. Those that fail will likely face the full scrutiny of both the public and their peers for their under-performance, with an implied threat to their ability to practise at all.
Whether such changes can truly lead to a quality revolution in general practice remains to be seen. Clearly, much will hinge on the willingness of GP leaders to take on this role and to have the skills in engaging in difficult conversations with their peers.
There has been considerable momentum for reducing the numbers of small practices through a movement to federated models. What the new plans for general practice inevitably mean is an accelerated shift to large GP-led clinical collectives that are subject to far more direct accountability for ensuring that high-quality and cost-effective care is delivered to local communities.
Moreover, additional plans for practice accreditation, GP revalidation, a revised Quality and Outcomes Framework (QOF), quality premiums, and the roll-out of “transparent” patient-reported outcomes all mean that general practice is undergoing a quality revolution that is likely to significantly challenge and change the nature of its work.
General practice will have to evolve rapidly to embrace this process, since the modernisation agenda will be transformative – moving it from a “cottage industry to a post-industrial model of care”. Much of the speed of this modernisation agenda will hinge on the quality of data and information that practices and commissioners can use and their willingness to take measures to improve performance where this is seen as necessary.
The inquiry into general practice quality
How to judge what high-quality general practice looks like is a central question here. It is a question that lies at the heart of The King’s Fund’s independent Inquiry into the Quality of General Practice, chaired by Sir Ian Kennedy, which will report towards the end of this year. A key emphasis of the inquiry has been to understand whether and how quality can be measured, and what approaches really lead to sustained quality improvement.
The inquiry is entering its final phases of work, having commissioned a range of research and discussion papers to inform its work (see Box 1). The findings have also been debated with key stakeholders through engagement events, an opinion survey and online discussion forums on the King’s Fund’s inquiry website (see Resource). As the Inquiry Panel begins to assess the evidence, and the reactions to it, it will begin to make a judgement on what the future of general practice should look like to sustain and improve care quality to patients.
Judging quality – two emerging lessons
The first key emerging lesson of the King’s Fund inquiry is that judging what quality looks like in general practice is problematic. Some aspects of a high-quality service are focused on clinical standards of practice, while others are based on patient experience.
Simply put, quality means different things to different people. A medic might, for example, emphasise the appropriateness of the clinical diagnosis or referral. What the public and patients think may be different, but is equally relevant. For instance, a patient may take it for granted that a GP will get the clinical aspects of the consultation correct, and instead prioritise better communication skills or an improved practice appointments booking system.
Quality also seems to be a politically driven phenomenon. The expectations of government are framed in policy and most explicitly expressed through funding decisions. Thus there are three parties involved in the negotiation of what general practice should be expected to do, and what constitutes good quality regarding both technical competence and interpersonal relationship issues. In broad terms they are:
In making a judgement about what high-quality care should comprise, inevitably trade-offs are to be considered in any definition of quality care. Is there a case, for instance, for trading off some elements of good practice in response to patient and public preferences that clinicians and managers might consider less important, or even irrational? How can a balance be achieved between the weight given to quality improvements associated with larger practices, as against patient disquiet at no longer having the personal relationships and continuity of care associated with smaller practices?
A very good example of this dilemma has been described in two reports to the inquiry on access to care and continuity of care.(1,2) Each report points to the fact that continuity of care – in the sense of being able to see the doctor of your choice over time – has become “taken for granted” for many years, despite it being an important determinant of satisfaction among both staff and patients. The findings support recent “discrete choice” experiments, which indicate that the public would generally opt for better continuity of care over speed of access when given a choice.(3,4)
The second key emerging lesson emerging from the inquiry is that measuring quality is essential if quality improvements are to be made – ie, “you can’t improve what you can’t measure”.
In the NHS, the development and use of quality indicators with general practice has become widespread – for example, through the use of balanced scorecards or the Quality and Outcomes Framework (QOF). However, some important facets of general practice are not easily quantifiable. For example, important issues such as the quality of care co-ordination and continuity of care – clearly valued as important by both doctors and patients – are left unmeasured and undervalued.
The quality of such elements that are intuitive or subjective is more challenging to measure, and a more creative approach may be needed to design a system that promotes their improvement. Hence, the inquiry has concluded that existing quality measures (such as QOF indicators) are important levers for improving quality, yet they represent a skewed understanding of what quality should represent.
“Patient centredness” is a characteristic underpinning the values of general practice, yet researchers have shown relatively few demonstrable clinical benefits from this approach – a fact they describe as “disappointing”.(5) It seems counter-intuitive to conclude that patient-centredness is not as “good” as the prevailing view would have us believe.
So this raises questions about whether the methods for measuring and evaluating its impact are not strong enough, or are misconceived, or are being applied inappropriately. As the inquiry’s work on the therapeutic relationship has shown, devising measures of quality for the various aspects of “patient-centredness” is an inherently problematic task, since the concept itself is multidimensional, without a direct association between process and outcome.(6)
However, it is central to this inquiry that these “hard to measure” aspects of care are included in any quality assessment framework. Only then can these features of general practice be defended and valued in an age where proof of quality through objective measures is the norm. If no attempt is made to measure these features, they are likely to be devalued – the consequent risk being the loss of some of the core values that have historically defined general practice.
The coalition government’s plans for general practice outlined through GP commissioning has some interesting potential to support quality improvements by developing collective incentives for providing higher-quality primary care geared as much to the needs of communities and local populations as to the patients they treat.
However, the transition to the new arrangements will need to be managed effectively to ensure that the focus on quality improvement and rigorous financial control lies at the heart of what they do. Otherwise, the suspicion that GPs may be skimping on what is best for their patients might arise – as they did under GP fundholding – because of the financial incentives under which they will operate.
To support the changes, the role and development of practice management (and consortia management) at both a provider and commissioner level will also be essential for success. As the early findings from the inquiry make clear, the data requirements alone in measuring the quality and cost-effectiveness of care delivery mean that GP commissioning must be done “at scale” if information of sufficient depth and quality can be made available for them to make sound commissioning decisions and to hold providers (including general practice) to account through peer-review.
The coalition government’s assumptions that large swathes of managerial bureaucracy can be stripped out of the system to save costs may be flawed unless GP commissioners can be persuaded to develop at a sufficient scale of operation. To do so, GP commissioners may have to club together to buy-in external support – something that will inevitably lead to a greater role for independent sector companies such as United Health and Humana.(7)
As general practice enters a new era, this will be the challenge for GP commissioning, particularly in the context of tight budgets. General practice will have to negotiate the different perspectives of quality, and this will require mature debate on how this can best be done and the ethical basis for these decisions.
1. Boyle S, Appleby J, Harrison A. A rapid review of access to care. London: The King’s Fund; 2010. Available from: http://www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_of_ca...
2. Freeman G, Hughes J. Continuity of care and the patient experience. London: The King’s Fund; 2010. Available from: www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_of_care/cont...
3. Gerard K, Salisbury C, Street D, Pope C, Baxter H. Is fast access to general practice all that should matter? A discrete choice experiment of patients’ preferences. Journal of Health Services Research and Policy 2008;13(Suppl 2):3-10.
4. Turner D, Tarrant C, Windridge K, Bryan S, Boulton M, Freeman G, Baker R. Do patients value continuity of care in general practice? An investigation using stated preference discrete choice experiments. Journal of Health Services Research and Policy 2007; 12(3):132-7.
5. Howie J, Heaney D and Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Family Practice 2004;21(4):458-67.
6. Greenhalgh P, Heath I. Measuring quality in the therapeutic relationship. London: The King’s Fund; 2010. Available from: http://www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_of_ca...
7. Naylor C, Goodwin N. Building high quality commissioning: what role can external organisations play? London: The King’s Fund; 2010.