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.