Inquiry into the Quality of General Practice in England

• Why are we doing this inquiry?
• Should we question the quality of patient care in general practice?
• What do we know about the quality of patient care in general practice?
• How does the NHS attempt to ensure high quality of care?
• How is this inquiry different from other initiatives?
• Why are measures of quality important?
• How will quality measures in the inquiry be derived?

Since the publication in 2008 of the NHS Next Stage Review, led by Lord Darzi, quality has been at the top of the policy agenda. Despite the introduction of the Quality and Outcomes Framework (QOF) that has provided incentives to general practice to improve the quality of patient care through pay-for-performance, the majority of the focus on quality has been concentrated on hospital services rather than general practice. If the NHS is to deliver on the vision outlined in the Next Stage Review of ‘putting quality at the heart of all we do’, then general practice needs to be brought into the picture.

One of the inquiry’s main aims will be to address the absence of standard measures for some of the core general practice activities, such as diagnosing illness, referring patients to specialists and handing out prescriptions, by producing a set of measures that can be used to help compare and assess the quality of patient care in different practices.

Our ambition is to help GPs and other professionals working in general practice judge the quality of what is being provided and demonstrate what high quality patient care looks like. We hope that in turn this will be used to help drive up standards for patients.

General practice in this country is rightly regarded as the envy of the world. Providing patients with primary care that is universal, comprehensive and free at the point of delivery has meant that the health service is ranked as one of the most progressive and high performing health systems (Starfield 1998).

We know too that services provided by general practice have been rated very highly by patients. For example, a poll of 2.3 million patients in July 2007 found that 84 per cent were satisfied with the level of access they had to GP services (Department of Health 2007). It is also generally accepted that the quality of GP-led care has improved over the years and in particular that the increased use of quality standards and protocols has helped to drive up the quality of clinical care.

However, while the overall quality of general practice has improved, we know there are significant variations both in the standards of individual practice and in the services provided.

The Healthcare Commission (until March 2009 the independent watchdog for health care in England) found that while patients were generally satisfied with GP services they were not being treated as ‘customers’ whose preferences for care were being met, but rather, they received what they were offered (Healthcare Commission 2005). This finding is also reflected in international studies where England remains comparatively weak in terms of the responsiveness of its services (Commonwealth Fund 2007).

There is remarkably little information for comparing the quality of patient care in different practices. For many aspects of care – for example, improving the health of their patients or managing those with long-term care needs – the roles and responsibilities of GPs remain poorly defined and contested.

The evidence that does exist on the quality of care in general practice for core activities such as diagnosis, referral and prescribing would suggest that there are significant variations in standards of care. For example:

Quality of diagnosis

No agreed standard measures or tools exist to review the quality of diagnosis in general practice yet there is evidence that making accurate diagnoses can prove difficult in older people and those with complex chronic illnesses. Problems appear to occur across a variety of conditions leading to variations in the quality of care patients receive and, potentially, unacceptable delays in diagnostic testing – for example, for certain cancers.

Quality of GP referrals

There is little objective evidence on the appropriateness or otherwise of GP referrals to specialists. However, studies have found a degree of variation in the quality of referrals and pointed to specific areas in which there could be improvement.

Quality of prescribing

The fact that most GP consultations result in a prescription for drug treatment, the growth of nurse-led prescribing and the direct supply of medicines through pharmacists, all make the quality of prescribing in general practice vitally important. A recent study 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 research in this area points to variations in the quality and rate of prescribing.

Since the early 1990s, primary care provision has moved from relatively isolated small general practices to larger multi-disciplinary teams with additional responsibilities for tasks such as active management of patients with long-term conditions, and preventive health measures such as smoking cessation, as well as responding to patient choice and commissioning hospital services.

One of the most radical changes has been the introduction of performance-related pay through the Quality and Outcomes Framework (QOF). As a result between 10 and 15 per cent of the remuneration to general practices is based on achieving a range of nationally set quality based targets. These are focused on ill-health prevention through the effective management of people with, or at risk of, developing a range of long-term conditions. QOF incentive payments have already been shown to have a positive impact on the nature and quality of care (Campbell et al 2007).

The quality of general practice is being monitored in a number of other ways. This includes government-led initiatives to regulate and improve the quality of care through the revalidation of GPs and to accredit every practice in the country, led by the Royal College of General Practitioners. All general practices will be required to register with the Care Quality Commission by 2011, while a new national GP Patient Survey should also highlight what patients feel about the quality of care they receive. The NHS Institute for Innovation and Improvement is also developing a Global Trigger Tool (GTT) as a way to measure ‘rate of harm’ in general practice and encourage patient safety. Finally, the National Institute for Health and Clinical Excellence (NICE) is overseeing a review of the cost-effectiveness of existing QOF indicators as well as developing and piloting new QOF indicators in general practice.

Through the Department of Health’s World Class Commissioning initiative, pressure is also being placed on the organisations which contract locally with GP practices. Primary care trusts (PCTs) are being encouraged to use key markers of quality on which to select, monitor and pay for best care in developing primary and community-based services. As general practice enters a more competitive environment, focusing on quality of care will be increasingly important in securing local contracts.

The inquiry comes at a key time in the reform of general practice and we are aware that there are a number of existing initiatives on the issue of quality in general practice. In addition to the work previously mentioned on accreditation and revalidation, the NHS Benchmarking Network and Primary Care Contracting are working together to establish a baseline set of markers of the quality of primary care – such as opening hours and the range of services available (NHS Primary Care Contracting 2008). Other ongoing studies include the Health Foundation’s Quest for Quality and Improved Performance and the Primary Care Pharmacists’ Association’s work on the quality of prescribing in primary care.

What makes this inquiry different is not only that it focuses on the quality of care provision from the perspective of the patient but also that it is specifically targeted at improving professional practice to achieve good quality care. Many of the key areas on which the inquiry will focus – such as the quality of diagnosis, referral and management of long-term conditions – have no standard measures of quality, yet it is these dimensions of care that dictate the patient’s experience and determine whether or not their health improves.

We will aim to ensure that our work will add value to the wider range of quality-led initiatives now being undertaken with general practice.

The ability to measure quality and create indicators of best practice can help to make services more accountable and regulation more effective at ensuring high standards; it enables health professionals to benchmark the quality of their care; and it offers a transparent way in which health professionals, managers, commissioners and patients can judge the quality of what is being provided.

However, we recognise that some aspects of care can be measured with greater validity and reliability than others and that there are some significant conceptual and practical problems to overcome when using quality indicators to lever improvements. In developing measures of quality, the inquiry will seek to address these issues.

Measures of quality can be developed in different ways: for example, using evidence from clinical guidelines or randomised control trials or consensus-building with expert informants (Naylor 1998). Indicators of quality can also be developed by combining scientific evidence with an understanding of the practicalities of applying such measures in practice – an approach pioneered by the RAND Corporation in assessing medical technologies in the 1980s.

In the context of general practice, this approach was used by RAND and the National Primary Care Research and Development Centre to establish a wide range of clinically-based quality indicators in general practice from the management of common clinical conditions, to prescribing and mental health care. They created a series of indicators based on evidence in the literature which were then given to expert panels who rated their validity and practicality. The measures were then field-tested against patient records.

This inquiry builds directly on this combined approach to the development of quality measures, but broadens the scope of the investigation from clinical indicators to assessing quality in terms of those key services that GPs and general practices provide.