Improving GP services in England: Exploring the association between quality of care and the experience of patients

This content relates to the following topics:

Part of Inquiry into the quality of general practice in England

Two key elements of the quality of health care provided by GPs are the Quality and Outcomes Framework (QOF), which rewards GP practices for achievement against a range of indicators of clinical quality, and the GP Patient Survey, which asks patients about their experience of using GP services.

Using data for more than 8,000 general practices in England, this paper examines the association between patients’ perceptions about the non-clinical aspects of care and practice performance on measures of clinical quality.

Key findings

  • Both clinical effectiveness and patient experience are key domains of health care quality. By considering the relationship between them, general practices can better understand the quality of care they are providing and identify areas for improvement.
  • Generally speaking, practices that deliver a good experience for their patients have higher QOF outcomes scores. The reverse is also true – practices whose patients are more negative about access to the practice and using its services generally perform less well on clinical quality.
  • With some exceptions, practices that perform poorly on both clinical outcome measures and patient experience are more likely to be located in London and in more deprived areas. These practices face special challenges.
  • Patients’ experience of using their GP services – especially ease of access – can affect their use of and interaction with those services, which could in turn affect the quality of their care.

Policy implications

Patients’ experience of using health care services is recognised internationally as a key measure of health care quality. The coalition government’s NHS Outcomes Framework for England recognises patient experience as one of five domains that will be used to assess the performance of the newly formed NHS Commissioning Board from 2013 onwards. The Board will have responsibility for commissioning primary care, so national primary care performance on patient experience and clinical quality will be of increasing importance in future. The new GP-led clinical commissioning groups will have a duty to improve the quality of primary care locally.


Alison Hill

Medical Director,
Londonwide LMCs
Comment date
20 November 2012
“Improving Health Services in England” draws on two large datasets: QoF outcomes and the national patient survey. However these quality indicators measure only what can be measured and do not answer the question of what lies behind the apparent variation in indicator scores, nor does it elucidate the nature of the relationship between Health Outcomes and patient experience. GP practices will need more than these two sets of indicators to understand what they can do to improve things for their patients.
This Data Briefing does not draw on the growing body of research into general practice that takes finer analysis of these and other indicators of quality in general practice , backed up by qualitative and action research. If the Kings Fund and its researchers are going to make a real contribution to improving the quality of care, it should spend less time jumping to conclusions and adversely criticising the effort of GPs and their staff, especially those in London. It makes a high level comparison between data from London and the English average- comparing the scores from the inner city with those from affluent areas is unhelpful and does nothing to aid interpretation.
The way in which the patient experience indicators are lumped together under the heading of “access” is misleading and has led to some unhelpful headlines in the Press. The Kings Fund divide the indicators, for the purpose of looking for relationships between QoF performance and patient experience, into “access, cleanliness, confidence in staff, dignity and respect, information, and involvement”. The “access” indicators include whether the patient can see the GP of their choice and whether they are involved in decisions about their treatment, which are key to developing trusting therapeutic relationships, and they separate these from “relational” aspects of care. Seeing the GP of choice and involvement in decisions about treatment (and the perception of time with the doctor), are all proxy indicators for the therapeutic relationship. In more detailed analyses, it is the seeing the doctor of choice particularly, and over time, which is associated with better health outcomes: less medication, fewer unnecessary investigations, lower use of A&E departments, better outcomes in diabetes care, fewer hospital admissions and lower cancer mortality .
Effective primary care depends on the therapeutic relationship between the patient and a trusted health professional. It also depends on the expert generalism which GPs provide. The “exceptional potential” of general practice is being undermined by contractual, demographic and social changes.
It was the prioritisation of rapid access to general practice that put the almost final nail in the coffin of personal care and relationship continuity. In reality relationship continuity and good access are inextricably linked but practices do struggle to do them both well, so innovative approaches, co-designed with patients and with appropriate safeguards, need to be developed so that time with “my doctor” can be maximised to good effect.
In most parts of London, especially , as in other large cities, GPs care for patients whose lives are made especially difficult by social disadvantage, often through language barriers. These patients also have multiple and complex health conditions at a younger age than the country as a whole. It is little short of a miracle, then, that London’s practices in deprived wards perform well on both “access” and “information” patient experience indicators. The current infrastructure of general practice militates against patients being able to have “enough time with their doctor”. In Glasgow, Mercer and colleagues have been demonstrated just how much time this might be.
Relationship continuity is usually better in small practices, but policy makers see small as “ bad and “ nonviable”. Let’s not throw the baby of effective therapeutic relationships out with the bathwater of “transforming health services”.

Hill A, Freeman G. RCGP Policy Paper. Promoting continuity of care in general practice. Royal College of General
Practitioners, 2011. [Online]. Available from: 2012
Chauhan M, Bankart JM, Labeit A, and Baker R. Characteristics of general practices associated with numbers of elective
admissions. Journal of Public Health. First published online: March 23, 2012. doi: 10.1093/pubmed/fds024
Mercer SW, Fitzpatrick B, Gourlay G, Vojt G, McConnachie A, Watt GCM. More time for complex consultations in a high
deprivation practice is associated with increased patient enablement. British Journal of General Practice, 2007; 57

Add your comment