Quality of care in general practice to be the focus of a major inquiry from The King's Fund

The quality of services provided by family doctors and other staff in general practice in England will come under the microscope following the announcement today of a major 18-month inquiry from The King's Fund.

The inquiry comes at a key time in the reform of general practice and will examine and collect evidence on the quality of care provided to patients. Despite the introduction of the Quality and Outcomes Framework that has provided incentives to general practice to improve the quality of patient care through performance-related pay, the majority of the focus on quality has been concentrated on hospital services rather than general practice.

There are few standard measures for some of the core general practice activities, such as diagnosing illness, referring patients to specialists and issuing prescriptions. The inquiry aims to address this by producing a set of measures in these areas that will help to compare and assess the quality of patient care in different practices.

The inquiry, which will report in September 2010, will be overseen by an expert panel consisting of leading figures within general practice under the chairmanship of Niall Dickson, The King's Fund's Chief Executive. It will examine a number of key dimensions of general practice, including patients' access to care, the quality of diagnosis and referral, and how patients with long-term conditions are cared for. In each dimension the inquiry will examine what high-quality care looks like, define the role of GPs and general practice in the delivery of that care, and recommend how it should be measured.

Niall Dickson said:

'General practice in this country is rightly regarded as the envy of the world. It is one of the key reasons why our health care system is so highly rated. But 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.

'Despite this, there is remarkably little information for comparing the quality of care in different practices. Our ambition is to help GPs and others judge the quality of what is being provided by creating a range of measures that demonstrate what high-quality patient care looks like. We hope that in turn this will be used to help drive up standards.'

To mark the launch of the inquiry, The King's Fund has published a short background paper on general practice and the remit of the inquiry. It says 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 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.

RCGP Chairman Professor Steve Field, a member of the expert panel, said:

'All our patients have a right to good quality care, whatever their postcodes or personal circumstances, and GPs work exceptionally hard to ensure this happens. However, there are certain parts of the country where we know that there are inconsistencies and provision can be patchy. The reasons for this are varied and complex and that’s why we welcome this independent review as an opportunity for primary care clinicians to lead and influence the quality debate which for too long has been dominated by secondary care. It will also enable us to better demonstrate good practice and to show that the vast majority of GPs are providing good and excellent care.

'The Inquiry is not just a lip service exercise or another stick with which to beat GPs. It will take into account the views and experiences of grassroots GPs working with patients around the country and I hope that as many of our Members and Fellows as possible will get involved and put their stamp on the future of quality care – for every patient.'

Fellow panel member Dr Michael Dixon, Chair of the NHS Alliance, added:

'Primary care clinicians should not fear a discussion about measuring quality. We have a good story to tell…yet not all primary care is as good as it should be. This inquiry can be a real opportunity for primary care to lead the way in discussing how we measure quality. Through this project, primary care can take the initiative in ‘doing quality to ourselves’ … otherwise others will 'do it to us', and the results of that may not be good. We are delighted to work with The King's Fund on developing meaningful quality metrics for primary care.'

The inquiry comes at a key time in the reform of general practice and GPs and other primary care professionals are coming under the spotlight from a number of other quality-led initiatives. The inquiry will not only focus on the quality of care from the perspective of the patient, it will also be designed to improve professional practice to achieve high-quality care.

A major part of the inquiry will be about engaging with frontline practitioners. The King's Fund will test out the inquiry’s findings through a series of events and surveys this autumn with GPs and other professionals working in general practice, as well as with members of the public, to ensure it is relevant, accurate, useful and effective. Professionals who would like to take part in these events are asked to register at gpinquiry@kingsfund.org.uk.

Notes to editors: 

  1. For further information or interviews, please contact The King’s Fund press and public affairs office on 020 7307 2585, 020 7307 2632 or 020 7307 2581. An ISDN line is available for interviews on 020 7637 0185. Embargoed copies of The King’s Fund’s background paper on the quality of general practice are available on request.
  2. The inquiry will be overseen by an expert panel consisting of: Dr Michael Dixon, Chair, NHS Alliance; Professor Steve Field, Chairman of the Royal College of General Practitioners; Ursula Gallagher, Director of Quality, Clinical Governance and Clinical Practice, Ealing PCT; Professor Martin Roland, Professor of Health Services Research, University of Cambridge; and Dr Rebecca Rosen, Senior Fellow, The Nuffield Trust. The King’s Fund’s Senior Fellow, Dr Nick Goodwin, will be the Inquiry’s project director. The inquiry will provide regular updates of its progress on The King’s Fund’s website – please visit www.kingsfund.org.uk/gpinquiry to sign up for updates.
  3. For example, studies have found: only 60 per cent concurrence exists between specialists and GPs on ‘reasons for care’ within mental health (Broomfield et al 2001); adherence to cancer referral guidelines varied from 63 per cent to 80 per cent for non-urgent referrals (Khawaja and Allan 2001); and there were concerns over the accuracy of referrals for presumed stroke (McNeill 2008). The full references for these studies are available in the background paper.
  4. A recent study in the International Journal for Equity in Health showed that patients in Scotland at higher risk of coronary heart disease tended to be linked to practices with lower quality GP services and lower prescribing rates. The reference is: McLean G (2008). ‘Practice characteristics and prescribing of cardiovascular drugs in areas with higher risk of CHD in Scotland: cross-sectional study’. International Journal for Equity in Health, vol 7, p18.
  5. General practice is coming under the spotlight from a number of directions, including government-led initiatives to regulate and improve care quality through the revalidation of GPs, while all general practices will be required to register with the Care Quality Commission by 2011. A new national GP Patient Survey should also highlight what patients feel about the quality of care they receive. NICE is currently overseeing a review of the cost-effectiveness of existing QOF indicators as well as developing and piloting new QOF indicators in general practice. In addition, through the Department of Health’s World Class Commissioning initiative, primary care trusts 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.
  6. The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.