The recently published King's Fund Report, Improving the Quality of Care in General Practice, suggests that there are significant opportunities for general practices in England to improve the quality of care provided to patients.1
This independent inquiry assessed evidence relating to 14 aspects of general practice, debated the findings in seminars attended by a range of stakeholders, including members of the public, and made a number of key recommendations about how general practice needs to change if it is to meet the challenges of gaps and variations in the quality of primary care.
The report suggests improvements could be made in a number of areas including care of patients with long-term conditions, continuity and coordination of care, patient involvement and engagement, and prescribing. It proposes that the skill mix in general practice be improved and that general practice moves from a ‘cottage industry to post-industrial care’.
The report, while generally welcomed, has also been challenged by a number of commentators. Iona Heath, for example, suggested that it assumed patients are ‘units of health need’ instead of individuals with their (our) own inconsistencies and foibles.2 While acknowledging the good intentions and scholarship of the report, we would also highlight three other key issues that diminish its overall utility and one important challenge thrown down to the profession.
SHARED DECISION MAKING
The report authors admit that they were unable to develop quality indicators for key aspects of care valued by patients, such as continuity of care and the therapeutic relationship between doctor and patient: both essential components of the ‘core business’ of general practice. Shared decision making, for example, is a process in which patients are encouraged to participate in selecting appropriate treatment from a range of management options on the basis of the best available evidence.3 It is a central tenet of the government's proposed health reforms (‘no decision about me without me’)4 and the report itself calls for a ‘new deal’ for patients. However, while measures of the use of patient decision aids to support shared decision making do exist,5 there is relatively little evidence that their use has a direct impact on the quality of care provided by GPs and improved clinical outcomes.6
No tools yet exist to capture the quality of care provided to patients with multiple long-term conditions,7 and the proportion of patients with multimorbidity continues to rise with an aging population. One recent study reported a prevalence of 29% of those attending a GP.8
MEASURING QUALITY
The Quality and Outcomes Framework attempts to measure clinical quality at the level of the individual patient and organisational quality at the level of the practice, and yet this only covers some 10% of general practice activity. Heath et al9 recommended that attempts to measure quality should take the unique complexity of general practice into account, to ‘move away from a linear approach to engage multiple perspectives and multiple levels’. Using a ‘care bundle’ approach to measure and improve performance in diabetes management, for example, would be hard to operationalise but might improve the Quality and Outcomes Framework; however, in itself, this is unlikely to be a satisfactory measure of quality of care in general practice.10
It is also interesting to note that in his foreword, Sir Ian Kennedy describes general practice as an area of health care which is ‘not given to self-reflection and self challenge’. Little evidence is provided within the report to support this contention. We would suggest that general practice is both one of the most measured and most reflective disciplines within the profession of medicine. From the establishment of Balint groups in the 1960s through the formation of Medical Audit Advisory Groups in the late 1980s and the rise of significant event analysis in the early 1990s, general practice has always been at the forefront of the profession in promoting reflective practice for GPs and trainees.11 Not for the first time, preconceived ideas about general practice run ahead of the evidence!
Perhaps most strikingly, the report, while scholarly and considered, lacks a sense of the spirit of general practice. It fails to capture the passion, the commitment, the love that most GPs have for their role. It also underestimates its complexity. An academic understanding that deprivation can lead to variation in quality does little to help the daily life of a GP practising at the bottom of a Welsh valley where the prevalence of diabetes is twice the national average. Instead we are left with a head teacher's report that suggests we have an ‘international reputation for excellence,’ but that we must all do better.
FROM COTTAGE INDUSTRY TO POST-INDUSTRIAL CARE?
Despite these caveats, the King's Fund report also provides us with a helpful challenge to improve the care of our patients. A future of post-industrial care is described, comprising the three key elements of measuring performance, improving care standards, and transparent reporting with the intent of eliminating unwarranted clinical variation, waste, and defects.12 With the advent of primary care commissioning groups, it will be important to ensure that these three key elements inform commissioning decisions, although not at the expense of individualised personal care from a skilled generalist.13
The creation of commissioning groups working within a post-industrial landscape may also help to address some of the variation in quality attributable to poor GPs rather than patient or deprivation-related issues.
While the direction of travel in recent years has been away from self regulation, a doctor providing poor quality care, not achieving the standards agreed and adhered to by his immediate peers, is more likely to be spotted, supported, retrained and then effectively and appropriately managed out by other doctors in a consortium than in the present system. The thinking required to create a fair and transparent post-industrial system may be the lasting legacy of the King's Fund report.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2011