Two years ago, independent health charity the King’s Fund threw down the gauntlet to GPs, urging them to take ownership of the quality agenda. For those who wish to pursue the challenge, the first task is to consider exactly what high quality general practice looks like.
Recent research from York University (see bullet points, below) suggests that, for patients at least, QOF is a measure of quality. Researchers examined the choice of practice made by 3.4 million patients and concluded that patients are more likely to choose practices that have earned higher QOF points.
The researchers estimated that a 10 per cent increase in QOF points would increase a practice’s list size by 14.4 per cent (see box one). Creating a quality practice is, however, likely to be a more complex activity than simply chasing QOF targets.
QOF and patient choice
- Researchers examined choices made by 3.4million patients from 994 practices.
- Patients were more likely to choose practices nearer to home with a higher proportion of GPs qualified in Europe, a higher proportion of female GPs and a lower average GP age.
- Given those factors, they found patients were more likely to choose practices with more QOF points.
- The effect held against patient age and gender groups and across areas with different socio-economic characteristics.
- The researchers argued that even small increases in the probability that a patient will choose a practice when its QOF increases could lead to economically significant increases in numbers joining the practice.
Dr Niti Pall, a GP in Smethwick, Staffordshire and lead for the NHS Alliance’s Innovation Network, works in an award-winning practice which spent time and money changing the way it worked.
The practice introduced innovations including group consultations for patients with long-term conditions; a network of volunteers offering support to patients; risk stratification; feedback cards handed out in all consultations; and triaging of all same day appointments.
Recognition for the practice would suggest peers and stakeholders believe the changes created a high quality practice. The practice also reduced emergency admissions by 40% and a patient survey found 39% of patients felt the practice had improved with 34% reporting better care and 46% easier access.
Dr Pall is under no illusion that making quality patient-centric can be hard work, admitting: ‘We started five or six years ago and it’s been a long hard slog.’
The Smethwick practice spent a lot of time on self-examination, an activity on which former chairman of the Healthcare Commission Sir Ian Kennedy placed emphasis when chairing the landmark inquiry by the King’s Fund into the quality of general practice.
The inquiry aimed to build up a picture of high-quality care; establish the role of GPs in delivering services; and explore how GPs can be supported to improve care. It examined a number of key areas, including patients' access to care, the quality of diagnosis and referral, and how patients with long-term conditions are cared for.
Sir Ian said primary care was not given to self-reflection and self-challenge but claimed the benefits of doing so could not be overstated in terms of improvements for patients. His inquiry concluded that although clinical outcomes were the ultimate measure of quality, such outcomes could only be achieved if appropriate structures and processes were in place to enable them.
This means a high quality practice must not only be clinically progressive but also forward thinking and innovative as a business.The King’s Fund found no single group of indicators could capture all dimensions of quality in general practice.
Dr Charles Alessi, chairman of the National Association of Primary Care (NAPC) and a GP in Kingston, agrees there is no easy route to establishing high quality practice.
‘QOF doesn’t necessarily equal how to develop a good practice,’ he says. ‘For a start, QOF is getting more difficult as time goes by and practices are so overwhelmed with the need to tick boxes as well as going through what an individual wants when they come to see you, there is a disconnect there.’
Dr Alessi puts continuity of care near the top of the list of factors for a practice seeking to deliver high quality care.
‘Half of all consultations are about long-term conditions, which is an enormous number. Continuity is more difficult for larger practices, but it is an important issue and practices need to design systems to get continuity as far as they can.’
Like Dr Pall, Dr Alessi considers patients vital partners in the creation of high quality general practice. ‘A really strong patient advocacy group within the practice really demonstrates how good a practice is,’ he argues. ‘The days of practices determining for themselves how things should be run are long gone.’
But Leeds GP Dr Richard Vautrey, deputy chairman of the GPC, warns of ‘the trend towards popularism’ and argues there may not be universal agreement on what is considered good general practice.
He adds: ‘The key is having enough time and resources to spend with patients which at the moment is very difficult. There are huge pressures on practices because of what you might call supplier-induced demand’.
Dr Pall’s practice redesigned its systems to try and reduce such demand.
She explains: ‘For example, we found out that if we didn’t offer an appointment to our patients when they think it’s urgent they will go to A&E. That behaviour may not be logical to a clinician so adapting to it can be a big culture change.’
Dr Alessi says practices also need to tackle demand by encouraging self-care and points out that research has shown a 5% increase in self-care will lead to a 25% decrease in access to health professionals.
‘A small increase in self-care is good for patients as well as professionals,’ he says. ‘Research has shown the person accessing care also considers it unnecessary but just has nowhere else to go.’
For Dr Alessi, a high quality practice will be involved in anticipatory care, for groups such as vulnerable elderly patients.
However, he and Dr Vautrey agree that cuts to general practice resources are making it increasingly difficult for practices to deliver such care.
Whether NHS reforms will have a positive or negative impact on service delivery remains to be remains to be seen. Dr Vautrey says CCGs’ key role is to match resources with the work that is expected of practices so quality of care is not undermined.
High quality practices address the needs of staff as well as patients. Dr Vautrey stresses that a practice must be ‘a good place to work in’; Dr Alessi adds that practices need to be liberated from micro-management so they are free to work in the way that works best.
‘A quality practice is one that meets the needs of both patients and clinicians,’ adds Dr Pall. ‘They should be practising evidence-based medicine but also making working life better for clinicians.’
With many elements to consider, the quest for quality is far from easy. However, with excellence comes greater professional satisfaction, happier staff, better patient care and a more buoyant business.