Are GPs ready to enter the world of quality improvement?

Understanding how the quality of care can be sustained and improved in general practice has been a core concern of the GP Inquiry commissioned by The King's Fund.

Leading GP advocates have written a discussion paper – Quality improvement in general practice – for the Inquiry that argues that while most GPs are committed to providing a high-quality service to patients, they do not routinely embed quality improvement (QI) in their work.

QI represents the collective effort needed to make changes that lead to better patient outcomes, better system performance and better professional development. However, the authors of the discussion paper suggest that most GPs hold an ambivalent attitude to the idea that they should continually and proactively seek opportunities to improve.

So what is it about the nature of general practice that means GPs are not engaged more instinctively in QI?

Here are three possible answers.

Data on performance of general practitioners benchmarks against average rather than best performance so most GPs feel comfortable with 'mid-table' performance. This, combined with generally high satisfaction rates among patients, means GPs do not see the need for change.
GPs still work in isolation from their peers, leading to an individualistic rather than team mentality. Few appreciate how their role fits within the overall system of care and what they might do to improve the NHS as a whole.
Many GPs are reluctant to engage with QI as they consider such ideas to be 'management speak', of no practical value, and likely to take up more time than they are worth.

And it has to be said that to date QI has not been implemented well. It is too often developed and perceived as a 'top-down' activity through which regulators and commissioners seek to manage performance and control activity. This erodes an important part of the very professionalism that enables QI initiatives to flourish.

However, evidence from higher performing health care systems, such as Kaiser Permanente in the USA, suggests that systematic use of QI tools achieves better outcomes.

So what would a QI-enhanced future for general practice in England look like?

It would include:

support systems that help GPs to make evidence-based decisions in clinical real time
transparent sharing of data about performance with patients, the public and peers
accountability for performance among peers combined with the judicious use of financial incentives
regular sharing of ideas and experience between practices and investment in education and training
for the minority of practices that perform poorly, governance arrangements for effective and timely remedial action.

The challenge, then, is to develop approaches to QI that promote trust, that GPs value and that demonstrably benefit patients. Looking ahead, the most innovative and forward-reaching GP consortia will be those that bridge the gap between a model of 'assumed trust' at practice level and the requirement to hold general practices to account for performance. GP commissioning consortia and their general practices will need support to develop this relationship, but it's likely that performance will be better among those that embrace the QI agenda than those that do not.

Read the report on quality improvement

Comments

Cloud cuckoo land.

The discussion paper takes insufficient note of tradition and structure of general practice in the UK.

Practices are subcontractors for primary care, driven by profit and paid by capitation. Quality carries no financial reward. Collecting data to satisfy the requirements for the quality incentive scheme does, and most practices invest resources to secure payments.

Practices use their resources/capacity (appointments) to provide care to patients. However the practice cannot decide whether high or low quality is given. For instance if a patient makes an appointment for a simple upper respiratory tract infection, the appointment is a waste: whatever care is given it will not alter the outcome and is therefore inefficient. This appointment is no longer available to provide preventive care for another patient with a chronic condition for whom intervention would have been useful.

The only way a practice can improve efficiency (and profits) is to deselect patients that do not make efficient use of the practice resources. In retrospect this is difficult, surgery attendances can only be reduced if they are difficult to obtain and unpleasant to experience as it is generally agreed that disenrolling patients that use disproportionate resources is not acceptable.

A quick look in our practice data reveals that 49 patients attended more than 9 times in the last year and 410 patients attended once. However, despite a similar amount of appointments taken, the 49 bring in about £3,000 and the 410 about £25,000. Only anxiety and being from the Indian subcontinent stand out as being overrepresented in the highest attending group.

As it is difficult to disenroll patients it is better to avoid accepting them in the first place, methods for this include:
- Excluding patients from deprived neighbourhoods
- Screening patients for illnesses (pre-registration interviews) or likely usage of resources (inspecting repeat medication lists)
- Excluding deprived patients by asking for proof of residence (utility bills, landline phone bills)

For instance there is a deprived estate that was covered by 5 practices in 2003. However with the changes to the 2004 GMS contract relating to patient removals, 4 practices excluded this estate from their practice area in 2004, meaning the only remaining practice covering this area has been experiencing increasing inefficiency. With the relatively low turnover of patients in the UK this will persist for many years, reducing resources, compounding inefficiency.

PCTs (initially PCGs for those with a long memory) were built on the same idea that local practices would unite and work on improving efficiency and the health of the local population. Unrealistic if you think about the factors that unite and those that divide practices. For instance, of the four practices that were permitted to exclude the deprived estate in 2004, two were run by the PCT, and the other two had members on the board of the PCT.

A similar division is already appearing for GP consortia, some practices happy to take a lead, eeking every penny from new opportunities, some disengaged but silent and willing to take whatever rewards for a quiet life and very few wasting resources on pointing out the pitfalls.

A final word on quality, this is taken as "quality as perceived by the customer". Alternatively you propose things that are "measurable". However in healthcare the customers are not good judges for the quality delivered. In the low risk environment of general practice substandard care has no adverse consequences. In a recent study there was no correlation between the quality scores of trained observers and patients (http://www.annfammed.org/cgi/content/full/5/2/151) indicating patient questionnaires are not a sufficient measure of quality. Concentrating on measurable items alone (like the QOF) gives an impoverished view of the patient experience and does not represent what most patients would define as quality (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1837344/pdf/bmj00246-0032.pdf)

I think this paper will be a very useful discussion tool over the months to come, as we debate and push forward a "professional plus" agenda to improve primary care

Dawda, Jenkins & Varnam offer a challenging list of recommendations for Quality Improvement in Primary Care, but can GPs do this on their own?

How does the focus on quality in General Practice balance with the need to manage the quality of care through the system as a whole. The gaps in a patient's care are likely to be visible to a number of other professionals on the patient journey. What role might they play together in optimising quality?