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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 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.’
Notes to editors
The report Improving the quality of care in general practice: Report of an independent inquiry commissioned by The King’s Fund is published on 24 March 2011. For further information or to request an interview, please contact The King’s Fund press office on 020 7307 2585 (or 07584 146035 if calling out of hours).
(1) Taken from The National Oesophago-Gastric Cancer Audit 2009.
(2) Taken from Delivering the Cancer Reform Strategy published by the National Audit Office in 2010.
(3) Taken from Prescribing costs in primary care published by the National Audit Office in 2007.
(4) Figures taken from the 2009/10 GP Practice Survey published by the Department of Health.
(5) Based on analysis included in the GP Practice Index published by Dr Foster in 2010.
(6) Figures taken from the 2009/10 GP Practice Survey published by the Department of Health.
(7) The inquiry was chaired by Sir Ian Kennedy, Emeritus Professor of Health, Law and Ethics at University College London and Chair of the Independent Parliamentary Standards Authority. Sir Ian is a former chair of the Healthcare Commission and chaired the public inquiry into children's heart surgery at the Bristol Royal Infirmary. He took over from the previous Chair, Niall Dickson, in October 2009, following his departure as Chief Executive of The King’s Fund.
The other members of the independent panel were:
Dr Michael Dixon, Chair, NHS Alliance
Professor Steve Field, former Chairman of Council of the Royal College of General Practitioners
Ursula Gallagher, Director of Quality, Clinical Governance and Clinical Practice, NHS Ealing
Dr Rebecca Rosen, Senior Fellow, The Nuffield Trust.
(8) The inquiry was launched in April 2009 and has undertaken an exhaustive examination of the evidence on the quality of care in general practice. It has published 14 research and discussion papers covering different aspects of general practice, held a number of events with stakeholders, frontline professionals and patients, and published an online survey of practice professionals.(9) The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.