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

Part of Inquiry into the quality of general practice in England

General practice is often regarded as the bedrock of the English health care system. Surveys consistently report high levels of trust in GPs and good levels of patient satisfaction with the services they receive in general practice.

However, other than data available through the Quality Outcomes Framework and the GP Patient Survey, very little information is published on the quality of care in general practice.

It was for this reason that The King's Fund set up, in April 2009, an independent inquiry into the quality of general practice in England. The aim of the inquiry, which was conducted by an independent panel of experts and chaired by Sir Ian Kennedy, was to help to support the work of general practice and to provide a guide to ensure that quality is at the heart of the service that it offers to patients.

Improving the quality of care in general practice is the report of the inquiry; it represents the most extensive review of quality across general practice carried out in recent years. Its work was informed by specially commissioned research and analysis of routinely available data across a range of aspects of general practice including: core elements of day-to-day practice - for example, diagnosis, referral and prescribing; non-clinical aspects of quality - for example, access to care and patient engagement; and areas where the role is shared with others - for example, maternity and end-of-life care.

The recent root -and-branch reforms of the NHS also have profound implications for the future of general practice, in particular the dual role it is being asked to play as both commissioner and provider of care that will mean GPs taking on responsibility for costs as well as outcomes of care. The timing of the inquiry's report is therefore propitious. General practice is at centre stage and quality must be the watchword.

In terms of the current quality of care, the inquiry concluded that the majority of care provided by general practice is good. However, there are wide variations in performance and gaps in the quality of care that suggest there is significant opportunity for improvement. Practices need a lot of support to encourage them to seek out and address variable performance, including: appropriate data and information; skills development; protected time; and appropriate rewards for excellence (as well as consequences for poor performance). Policy-makers, regulators, commissioners and professional bodies could all do more to create a better environment that supports general practice in its quest for quality.

Nigel Mathers: Inquiry into the quality of general practice

Professor Nigel Mathers, Vice-Chair of the Royal College of General Practitioners, gives his response to the final report of the Inquiry into the Quality of General Practice in England.

Comments

Health workers including GPs are understandably sensitive to cristicism but surely it is no mystery that the services provided are not just inequitable but at times shoddy, uncaring and unprofessional...disempowered people especially are still unable to speak out....it is therefore unpleasant to have 'mystery pseudo patients' calling at surgeries to check performance but it is a valuable addition to protecting the health and lives of individuals. There could also be a system devised whereby people who are concerned could bypass the usual often farcical complaints systems and instead raise issues with a named person at the Kings Fund. It is no use just producing reports.

In response to Paul Johnson's comment my point was that in our work regarding the importance of generalism for primary care/general practice we suggest that primary care does have a role for doing all of things mentioned by Dominic and from our model developed from reviewing published literature, practitioners and researchers have suggested that is what they do.

What we have found is that generalism may be not only important to quality of care but fundamental to it and when it is embodied and expressed in practice it may be important to addressing the problems of health inequalities you say have been avoided by the government. I do not disagree that health inequalities are often the elephant in the room, but I was not making a point about this.

Nick mentions that general practice has a role to play in social determinants of health, health advocacy and community oriented primary care, perhaps some of the cohesion and leadership comes from having a clearly articulated philosophy of practice that underpins the primary care setting.

Dr Victoria Palmer (Applied Ethicist)

Excellent report that arrives in a very cross-road moment to take guidance on our way to make more sustainable our public health system in Catalonia. Good focus on health results, and highlighting the need for a more coordinated multi-approach long term care orientation.

Dr Dominic Harrison's concern is an understatement and certainly not answered by Victoria Palmer - I thought a chapter on health and inequalities had been omitted. General practice along with the NHS has almost completely avoided this responsibility for 60 years. We know that the health of the nation is a societal decision with the best health services perhaps able to contribute 17% of the nation's health (Canada 2009 - Thailand 1988 - new public health law enacted in 2007). But where is the leadership in health not sickness services in UK?. The new Government legislation places this with the GP, public health and the town hall - but who leads and where are the skills? If this is King's fund steerage - well!

The use of the word promotion in any health policy is a give-a-way to no leadership or hands-on involvement. Patient choice and patient centred care are other sops to a nanny state population which doesn't see it's own role in the causes of ill-health. I wonder what Sir Michael Marmot will think of this

Many thanks for your posts

In response to Dominic Harrison, I agree with his points - given the breadth of the issues the Inquiry had to focus on some key areas of quality. However, we do advocate strongly in the report for general practice to play a key role in these areas - spoecifically in developing a 'population health' focus that would imply a community-orientation to its way of working. I would draw your attention to the published papers in the GP Inquiry series on tackling health inequalities and health promotion that covcers some of the potential for general practice to focus in these areas. Certainly, I think in England we perhaps undervalue the role of primary care in promoting citizenship and community identity - something that's very strong in the rationale for community-oriented primary care in other parts of Europe.

In response to John, we have not looked at issues in specific surgeries so you would need to address any questions/queries you have to the local PCT.

Best wishes

Nick

It is exciting to read that there is a renewed focus on generalism within general practice. In our narrative review and synthesis on generalism (2007) we identified how much use of the term there was with little to know explanation or definition of what it meant. The Kings Fund defines generalism as patient centred care and holism. We found that the concept is more that this and more than an approach or knowledge base; it relies on the interaction of three dimensions of being, knowing and doing. It is difficult to articulate the being dimensions of practice and these are often what patients value most. Since the Fund allows reference to publications that are relevant to the topic, for those interested in reading more about how we describe generalism as a philosophy of practice and the conceptual model of generalism identified from published literature, you can source the report from anu.edu.au/aphcri/Domain/Workforce/Gunn_1_approved.pdf

I am keen to hear from those interested or engaged in generalism research and I think our model captures Dominic Harrison's point about the role of primary care in the health system.

Dr Victoria Palmer Applied Ethicist

Please advise if you reply to specific GP surgery issues. I certainly have issue with two GP surgeries I have been involved with personal long term health problem.

The report contains many good elements in relation to treatment and care but seems to completely miss the issue of the Primary Care system role in adressing the Social Determinats of Health, Health Advocacy, Community Oriented Primary Care and many of the wider issues raised by the WHO (2008) Now More than Ever report on primary care. This is a missed opportunity and a surprising ommission for the Kings Fund

Thanks for good reading material with important new topics highlighting General Practice, a way forward in improving quality of care in future,locally and internationally.

Wish you all a bright future in General Practice.
Dr Shoaib Qureshi

regarding the GP patient experience - clearly, 'patient' is the operative word when attempting to make an appointment with a chosen GP. Although anecdotal, I have heard more than once from GP's with home responsibilities, that since the new deal - struck by incompetant bureaucrats and the BMA - part-time GP rewards are so great they do not need to work more than a 2 or 3 day week; thus, a wait of 2 or 3 weeks sometimes for GP of choice. I imagine the only way arround this is to employ more GP's; but that of course would eat into the budget and current policy seems to favour a financial imperative rather than patient experience.