General practice must embrace change to improve quality of patient care

A major inquiry commissioned by The King's Fund has concluded that, while the majority of care provided is good, there are widespread variations in performance and gaps in the quality of care delivered by general practice.

The inquiry's report, Improving the quality of care in general practice, strongly endorses the principle that GPs should be generalists rather than specialists. However, with GPs set to be handed £80 billion of public money and a central role in implementing the government’s health reforms, it calls on general practice to embrace radical change if it is to maintain its international reputation for excellence. The report highlights evidence of variations in the quality of clinical care including:

• variations in the quality of diagnosis – for example, analysis shows that one-third of patients with stomach or oesophageal cancer requiring urgent referral to hospital are given a non-urgent referral (1)

• disparities in the rate of referrals – for example, there is an eight-fold variation in the rate at which practices urgently refer patients with suspected symptoms of cancer to specialists (2)
• variation in the quality of prescribing – it is estimated that the NHS could save at least £200 million a year through more efficient prescribing of drugs such as statins.(3)

The report also highlights concerns that continuity of care is worsening, despite evidence that being able to see the same GP is more important to patients than speed of access. Variations in the experience of patients and co-ordination of care highlighted by the report include:

• in the lowest performing practices, only just over a quarter of patients are able to see their preferred doctor (4)
• wide variations in admission rates for patients with conditions that could be treated outside hospital – more effective management of medical conditions in the community could save the NHS several hundred million pounds a year (5)
• only 1 in 10 patients with long-term conditions report being told they have a care plan, despite a policy commitment that all of them should have one. (6)

The inquiry, which was conducted by an independent panel of experts and chaired by Sir Ian Kennedy, represents the most extensive review of quality across general practice carried out in recent years and brings together a wide range of evidence for the first time. It found a lack of reliable data about many aspects of care, underlining the need for much greater transparency and a stronger focus on measuring quality within general practice.

The report highlights a number of challenges facing general practice, with demographic change, higher patient expectations and new technology changing the environment in which it operates. To meet these challenges, it encourages GPs and other primary care professionals to build on changes already taking place to transform the way general practice works by:

• accelerating the trend for practices to work as multi-professional teams, with GPs working closely with specialists and other professionals within and outside the practice

• delivering a 'new deal' for patients, which involves them much more closely in decisions about their care

• GPs moving from being 'gatekeepers' to 'navigators', co-ordinating care for people with complex needs, signposting patients to other public services and being held accountable for the quality of care provided

• accelerating the shift away from small practices working in isolation towards 'federated' networks of practices working more closely with one another and with other professionals

• practices looking 'beyond the surgery door' by focusing on prevention, taking a more active role in public health issues such as obesity, and reaching out to deprived communities.

The report also highlights the need to create a much stronger focus on quality improvement within general practice, with GPs taking responsibility for driving this forward based on:

• a much stronger commitment to transparency, with more information about quality of performance shared with patients, the public and fellow professionals

• a strong emphasis on peer review, with professionals benchmarking their performance and providing each other with challenge and support

• better use of information, data and information technology to monitor and measure quality, including a much stronger commitment to collecting and acting on patient feedback.

Sir Ian Kennedy, Chair of the independent panel, said:

'General practice is the bedrock of the NHS and the profession is rightly proud of the contribution it makes to the health of the nation. But the environment in which it operates is changing and the profession must change with it. I hope general practice will rise to the challenges set out in this report and seize the opportunity provided by the development of GP commissioning to deliver the improvements in quality needed.'

Chris Ham, Chief Executive of The King's Fund, said:

'Although general practice in this country remains the envy of the world, there is no room for complacency. While many practices have been at the vanguard of innovation and quality improvement, too many GPs remain unaware of significant variations in performance and do not give priority to improving quality. I hope this report will act as a spur to GPs and others working in general practice to accelerate the pace of change.'

Read the final report: Improving the quality of care in general practice: Report of an independent inquiry commissioned by The King's Fund