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Raising the game

27 June 2011

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Senior Fellow
The King’s Fund

Nick works as Senior Fellow at The King’s Fund and was the project director of the two-year inquiry into the quality of general practice in England. Nick is the priority lead for the Fund’s work on integrated care and the management of long-term conditions

In March this year, The King’s Fund(*) published its report of the independent inquiry it commissioned into the quality of care in English general practice.(1,2) The report was published in late March this year, at a time of great change for the NHS in England, with root and branch reforms having a potentially profound effect on the future role of general practice – especially in its lead role within GP commissioning consortia, which will require GPs to become responsible for the costs, as well as the outcomes, of care.

The publication of the report was therefore timely – as general practice moves to the strategic centre of the NHS, so quality must be its watchword. This also comes at a time in which the demands and expectations of general practice are the highest they have ever been, and growing. Patients now expect a more responsive service and want to be engaged more actively in making decisions about their care. New technologies are transforming the way practices operate as businesses, while patients can, and want, to interact with general practice in different ways as a result.

More fundamentally, an ageing population and increasing numbers of people living with multiple chronic illnesses are requiring general practice to change and broaden the nature of its business – for example, through the establishment of federations of general practice to support a wider range of available services to registered patients, and the beginnings of new alliances with social care services, community staff and hospital providers that support integrated models of working.

This is also an age of increasing transparency in which good professional practice can no longer be assumed but must be demonstrated. Patients and those who commission and regulate services increasingly require information on quality, and professionals themselves want to be able to benchmark their own practice and services to improve the quality of care they provide. In the current financial environment, general practice is likely to be stretched further in the name of productivity and cost-effectiveness.

The independent inquiry
The study of quality in general practice is an underdeveloped area and, other than the Quality and Outcomes Framework (QOF), which is narrow in scope, there is relatively little published information on the quality of care in general practice.
It is for this reason that The King’s Fund sought to establish the inquiry, the final report of which represents two years of work and the most extensive overview of quality of care across general practice that has been carried out for many years.(3,4)

The principle purpose of the inquiry was to provide evidence-based lessons to help support quality improvements in general practice and to provide a guide to ensure that quality is at the heart of the service practices offer to patients.
The evidence contained in the inquiry’s final report represented the collation of data from a series of research papers on key dimensions of care that it commissioned, supplemented by secondary analysis of up-to-date published data sources.(3)

A key element in the design was to ‘test out’ these findings with primary care-based professionals and other stakeholders, and also to then examine the ways in which general practice might collect data on care quality to support and embed a culture of quality improvement.

Key findings
Overall, the inquiry concluded that the majority of care provided by general practice is good. For example, trust in the quality of care provided remains high among patients. However, it also uncovered wide variations in performance between practices and gaps in the quality of care that suggest there is significant opportunity for improvement.

In particular, it found that more needed to be done to support those working in general practice to make them aware of variations in quality, and to take action if these are unjustified. A better and more consistent standard of care is possible, and practices that underperform need to be challenged to improve and, where appropriate, be supported to do so.

The inquiry suggested a number of key areas in which considerable improvements in the quality of care provided in, and through, general practice might be made, including:

Ensuring that all patients receive all their recommended care as defined in best-practice guidance, for example in the prescribing of low-cost statins and in delivering care to people with long-term chronic illnesses.

Reducing unscheduled hospital admissions for those people whose conditions could have been managed in primary care.

Addressing wide variations in patient experiences, especially in enabling them to become more involved in making decisions about their own care and also in supporting them to self-care.

Improving the level of continuity of care and taking on more responsibility for the co-ordination of care of patients where care is received from multiple providers. This is particularly important for the frail elderly and those with long-term chronic and mental conditions, who often receive poorly 
co-ordinated care.

Much of the future quality agenda for general practice, therefore, is how it relates and integrates the care that patients receive with other care providers. While the inquiry concluded that generalism and general practice lie at the heart of the future of the NHS, it needs to adapt significantly to become a more effective hub around which the wider system of care 

Embracing quality
General practice has already evolved significantly from its origins by moving towards a team-based model of care, embracing an ever-growing range of care and services, and working in larger groups and federations of practices.

However, if general practice is to meet its new responsibilities and maintain its international reputation for excellence, it needs to further adapt. General practice will need new skills, make greater use of information, engage with local authorities and other public services, and be more open, transparent and accountable for the quality of care.

While many general practices are engaged in quality improvement initiatives and are proactive in seeking to make improvements, quality improvement is not yet embedded as a way of working routinely. 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). Policymakers, regulators, commissioners and professional bodies could all do more to create a better environment that supports general practice in its quest for quality.

Support for the coalition government’s NHS reforms, and its GP commissioning consortia in particular, appears to be on the wane among primary care professionals. Yet connecting providers and commissioners more closely together does have advantages – for example, in its potential ability to drive improvements and challenge poor practice through a peer-led process.

This needs an appropriate system of rewards and penalties that can be genuinely influential and that focuses on local priorities. A more open culture is required that balances the ability to trust general practice to get on with the job, and mechanisms for controlling or shaping what it needs to do. General practice is more likely to be engaged in quality improvement in care where it ‘owns’ the agenda, and where there is transparency in the sharing of data at a local level between professional peers and the public.

The future of general practice
From the evidence presented to the inquiry, it is clear that the future of general practice is likely to herald a radically different way of working. The skill-mix in general practice will become more complex, and practices will need to work across federations of practices in which they operate and the GP commissioning consortia of which they are likely to be members.

These changes will not only see a growing role for nurse practitioners, they will also facilitate a much wider range of professionals working alongside GPs. There is also an implied and significant role in the new agenda for practice managers – particularly in providing and analysing data from practice-held records for the purposes of peer review, but also in the supporting federated models of working, relationships with GP commissioning consortia, and more shared care arrangements with other care providers.

In the future, one might envision the basic unit of activity changing from a face-to-face consultation with a patient where the GP acts as a ‘gatekeeper’ to the provision of a highly co-ordinated and multidisciplinary service that proactively supports patients in navigating their way around the system and helps them to manage their own health.

In this regard, general practice will need to strike a new deal with patients in which patients become active participants in the care and services they receive. This is important since effective engagement with patients is intrinsic to quality improvement.

To achieve this, general practice will need to operate at a scale commensurate with the demands placed upon it and GPs. Those leading GP commissioning consortia must set out this vision clearly and lead change from the front.

The authors of the inquiry’s report hope that general practice will embrace its broad thrust and recognise that it provides the building blocks for a new prospectus on which general practice can ensure that quality remains at the heart of the 
service it offers to patients.

1. The independent panel 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. The other members of the independent panel were: Dr Michael Dixon, Chair, NHS Alliance; Professor Steve Field, former President of the Royal College of GPs; Ursula Gallagher, Director of Quality, Clinical Governance and Clinical Practice, Ealing.
The King’s Fund. Improving the Quality of Care in General Practice. Report of an independent inquiry commissioned by The King’s Fund. London: The King’s Fund; 2011.

3. All of the inquiry’s published research and reports, including a recording of the launch event, can be found at The King’s Fund website at:

If you have any comments or questions about the inquiry then please contact the inquiry’s project director, Dr Nick Goodwin, at 
[email protected]

* The King’s Fund is an independent charity that seeks to understand how the health system in England can be improved. The think tank works with individuals and organisations to shape policy, transform services and bring about behaviour change.