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Practice Performance - PCTs' use of balanced scorecards

Nick Goodwin explains how this method of assessing the quality of GP services may be used in future.

Patients' satisfaction with waiting times at the surgery and GPs' 'soft' skills will be assessed
Patients' satisfaction with waiting times at the surgery and GPs' 'soft' skills will be assessed

General practice is becoming saturated by plans to collect data on various quality measures.

In addition to current requirements, GP revalidation is on the way and, from 2011, the Care Quality Commission practice accreditation scheme for registering will come into operation. To add to this mix comes the 'balanced scorecard'.

What is a balanced scorecard?
Balanced scorecards draw together data from a variety of sources in an attempt to provide an objective and rounded view of the quality of care.

Most PCTs are seeking to work with local GP practices to develop balanced scorecards as a means to judge and manage performance and potentially to help them commission and reward good quality services.

In October 2009, the DoH published Improving Quality in Primary Care on the different methods to secure continuous quality improvements.

It is clear from this that PCTs must bring together different performance indicators into a single 'basket' for a balanced assessment of performance and development - the 'balanced scorecard' - with the explicit intention in the future to make such assessments available to patients and the public.

The DoH expects all primary care providers to publish quality accounts by 2011/12 to ensure that accessible, reliable and comparative information on availability and quality of services is available to the public.

How have scorecards developed?
The DoH has been working with the balanced scorecard concept for a number of years, for example, in the use of 'star ratings'.

Applying the principle to primary care is an attempt to stimulate a discussion about current levels of quality and performance with the ultimate purpose of pulling 'quality up to the best'.

The DoH has developed commissioning guides that include details of the quality scorecards that many PCTs already use. The NHS Primary Care Commissioning website has examples of local scorecards and a guide to implementing them.

The underlying philosophy is that scorecards should be based on a jointly agreed vision with practices. The process of developing the scorecard should stimulate joint discussion between commissioner and provider on how to understand local performance, examine current strengths and weaknesses, and identify local priorities.

Establishing and running a scorecard system is likely to be a time-consuming process that requires specific resources, so all parties need to be clear and confident about how and why it is being undertaken.

From a PCT's perspective, the scorecard enables it to benchmark trends and variations across a health community.

GP practices would be able to see how they perform in relation to their peers and, potentially, stimulate a process of learning and support to improve and spur 'poor performers' into action.

What do scorecards look like?
Most of the data comes from material publicly available. The DoH has developed a Primary Care Commissioning Support Applicator (request this by emailing ppcssteam@dh.gsi.gov.uk) with input from more than 20 PCTs. It currently contains 101 publicly available metrics that could be used locally.

This includes data on current health needs; socio-economic population data; various structural measures (such as configuration and capacity of practices) as well as a range of 'result' indicators - see box.

Will scorecards stimulate improvements?
While balanced scorecards are not (yet) linked to financial rewards, the clear purpose is to highlight comparative performance between practices across such a range of quality measures and so stimulate quality improvements. For example, the majority of balanced scorecard approaches seek to rate general practices on their comparative performance by giving them an A, B or C grade.

There may be problems with such an approach. For example, referral and prescription rates are likely to vary greatly between practices as a result of their differing patient profiles. So a comparatively high or low rate may be entirely justified on quality grounds.

What is your view?
Although the DoH is confident that the balanced scorecard approach, when appropriately developed locally, should stimulate quality improvements, there are others who feel that it is a rather crude tool to apply to individual practices and may yield relatively few benefits.

The King's Fund is currently running an inquiry into the quality of general practice that is seeking opinions on such issues. To get involved you can visit The King's Fund website or e-mail the inquiry team direct at gpinquiry@kingsfund.org.uk.

  • Dr Goodwin PhD is senior fellow at The King's Fund and project director, The King's Fund inquiry into the quality of general practice

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