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Tuesday 27 September 2016
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Special relationship in danger?

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What do you believe to be the most important aspect of general practice? Clinical excellence? Fast and easy access? Impressive Quality and Outcomes Framework (QOF) scores? And just what is it that makes a practice “good”? Furthermore, what separates a “good” practice from an “excellent” practice?

We recently celebrated the success of general practice at the annual MiP Awards presentation, and once again I had no little sympathy with our judges, who – as they each confessed – had an extremely challenging task of selecting one practice as the winner where numerous entrants had justifiable reason to declare their practice worthy of the trophy.

Ultimately a victor needed to be chosen in each of the six categories, and I’ve no doubt that if you cast your eye to our winners’ profiles in this issue, you’ll agree that each of these practices can be accurately described as “excellent”.

Sometimes, though, it’s hard to define precisely why a practice is really special and just why it works so well.

This issue, we speak with Chris Ham, the Chief Executive of The King’s Fund. The think tank is, at the time of writing, about to publish the findings of its 18-month Inquiry into the Quality of General Practice in England, which set itself the task of trying to identify whether and how practice quality can be measured. Like the challenge we set our award judges, this is no mean feat.

In our last issue, Dr Nick Goodwin, the project director of The King’s Fund’s inquiry, acknowledged the “hard to measure aspects of care” intrinsic to general practice. Dr Goodwin’s inquiry has rightly included the consideration of these aspects in its quality assessment framework. As he wrote in MiP: “If no attempt is made to measure these features, they are likely to be devalued – the consequent loss of some of the core values that have historically defined general practice.”

I would argue that the doctor-patient relationship, and continuity of care, number among those “core values” essential to general practice, that are not quantifiable or recordable. And I would not be alone in that assessment. According to a recent survey conducted by The King’s Fund to complement its inquiry, more than half (57%) of GPs and other practice-based professionals said continuity of care should be the main priority for improving the quality of general practice.

Interestingly, this popularity was in stark contrast to “access to care”, which just one in five of the survey respondents believed should be prioritised. So much for the drive to increase practices’ opening hours, itself a strong priority for both the current and the last government.

But the survey results should be viewed with a certain degree of caution; it also found that just over half believed the QOF to be the most effective approach to quality improvement, while 57% believed patient surveys to be the least effective approach. As Dr Goodwin said: “Are pay-for-performance measures really a more important tool for quality improvement than initiatives such as patient feedback?”

It may be that patient surveys can offer up misleading, even skewed, results, and that the emphasis on access to care has been used as a political weapon. Nonetheless, both will be seen as welcome and important developments by many patients and should not be dismissed in a knee-jerk reaction against a more transparent and accountable service.

But continuity of care is clearly important to patients too. Recent research has showed that patients would generally opt for better continuity of care over speed of access when given a choice. This is one aspect of general practice that patients and practice professionals are agreed upon. Particularly for patients with long-term conditions, seeing a doctor who knows you, your medical background and your family history is of immeasurable value. The doctor-patient relationship, even in a modern age in which people find themselves less rooted, is often based upon a shared familiarity and understanding that goes back years. This relationship, based on mutual respect and trust, is a cornerstone of general practice.

However, in the light of the government’s radical healthcare reform, could this change? Some warn that GPs’ imminent transition from providers to commissioners of care could threaten the doctor-patient relationship. This view was expressed by no less than Dr Clare Gerada, the new chair of the Royal College of GPs, who recently suggested that the reforms could lead to a nightmare scenario in which disgruntled patients lobby outside their practices in protest at health funding decisions made.

“At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, ‘You’ve got a nice BMW car, but you will not allow me to have this cytotoxic drug that will give me three more months of life’,” she told the Guardian newspaper.

Dr Gerada said that making doctors “the new rationers” of NHS care could diminish patient trust and turn them into “customers” who shop around trying to get the best treatment for their condition.

She said: “I’m concerned that my profession, GPs, will be exposed to lobbying by patients, patient groups and the pharma industry to fund or commission their bit of the service. There could be letters from MPs and patient groups, and begging letters from patients.”


Dr Gerada puts forward a rather extreme scenario, but could it be that this changing role does alter the way patients see their GPs? Doctors have already been subjected to negative press headlines over the 2004 pay deal, but even then they continued to be regarded as very much part of the community, with financial decisions taken “elsewhere” by primary care trusts and the National Institute for Health and Clinical Excellence (NICE). Forced to take tough funding decisions over drug allocation as well as responsibility for reducing health spending elsewhere, could GPs find that the public mood takes an even darker hue?

I do hope that this will not be the case. Most members of the public will recognise the extraordinary financial state the country faces and appreciate that difficult decisions have to be made. Given that the health reforms will demand new integrated relationships between practices as members of consortia or federations (as Dr Maureen Baker of the RCGP explains in our attached issue of GP Business), it would be unwelcome and ironic that the most important relationships of all – between patients and their local practice – should diminish.

As demonstrated by the MiP Award winners, general practice is at it best when this relationship is strong. Take the Lindley House Health Centre in Oldham, in which practice members went out into the community to find out from local teenagers how the surgery could improve and develop its young person’s services. Or the Community Health Centre in Highfields, Leicester, which engaged with their community and encouraged them to look after their health, with significant outcome improvements.

It is this level of interaction with patients, guided by good managers, that makes general practice really special. The relationship a practice has with its local community is the core value that should never be devalued. Let’s hope that does not change – when patients take an “us and them” attitude to general practice, we will know that something has been lost that is beyond measure.