Inquiry into the quality of general practice in England

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), which provided incentives to general practice to improve the quality of patient care through pay-for-performance, 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.

Our ambition was to help GPs and other professionals working in general practice to better judge the quality of what is being provided, and to use data and information to support quality improvements that help drive up standards for patients.

General practice in England 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 our health service is ranked as one of the most progressive and high-performing health systems (Starfield 1998).

We also know that general practice services 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 practices has helped to drive up the quality of clinical care.

However, we also know there are significant variations both in the standards of individual practice and in the services provided. For example, the Healthcare Commission 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).

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, including active management of patients with long-term conditions; preventive health measures, such as smoking cessation; 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. 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 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 ones.

Through the Department of Health's World Class Commissioning initiative, pressure is also being placed on the organisations that 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 development of frameworks that use a range of quality markers and indicators to assess quality has become a crowded field of activity in primary care. The Inquiry will seek to add value to this activity through a comparison and critique of the measures used to assess care quality against those developed through research.

Other than the QOF, 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. But 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 (for example, certain cancers), which lead to variations in the quality of care patients receive and, potentially, unacceptable delays in diagnostic testing.

• 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 quality of prescribing in general practice is vitally important, as most GP consultations result in a prescription for drug treatment, and there is a growth in nurse-led prescribing and the direct supply of medicines through pharmacists. 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.

The Inquiry came at a key time in the reform of general practice.

What made this Inquiry different is not only that it focused on the quality of care provision from the perspective of the patient, but that it specifically targeted at improving professional practice to achieve good-quality care. Many of the key areas in the Inquiry - such as the quality of diagnosis and referral and management of long-term conditions – had 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.