Painting a credible picture of general practice care quality?

Today the Health Foundation has published its independent review into indicators of the quality of care provided by general practices in England following the announcement by the Secretary of State for Health back in June. Having been closely involved in this piece of work, and being one of the review’s co-authors, this blog is my personal reflection on the review process and hopefully provides a little snapshot of our recommendations and findings.

The last few months have gone incredibly quickly and while we initially thought the review was a technical task focused on indicator development, it soon became clear that there were some broader strategic issues to consider before focusing on individual indicators.

The first question seemed to be, what are published indicators actually for? As well as publishing indicators to improve transparency (as an end in itself), we identified four main purposes – to help improve care (for practitioners), to strengthen patient choice and voice (for the public), to improve the accountability of general practices (for example to NHS England, the Department of Health and regulatory bodies) and to aid research (for the academic community).

Within the short timeframe available for the review (June to September 2015), the Foundation consulted with a wide range of organisations and individuals with an interest in how information about general practice care quality is collated and published. We assessed the literature, analysed the indicators currently used as well as the websites on which they are published, and worked with insight agency BritainThinks to understand the public’s views.

We found considerable support for the sharing of information about the quality of general practice in a meaningful way. Intelligent transparency - if undertaken collaboratively - has the potential to support improvements to health care services for the population of England. But throughout the consultation exercise we found very low awareness and usage of some of the resources that are already available nationally.  

One thing that might help with awareness is to consolidate the many websites currently sharing information about general practice quality. Personally, I found it astonishing just how much duplication there is across different websites – which can be very confusing for the public and practitioners. In the review we recommend that the Department of Health and arms’-length-bodies should collaborate to achieve this consolidation, make explicit who the primary audiences are for future publication of any indicators, and do much more market research to find out what information these audiences want.

We considered whether it would be possible to develop a composite score that could provide an overall view of general practice quality. In the report we strongly advise against making a composite score out of quantitative indicators alone. Any composite is unlikely to provide a credible picture of the quality of care and so would be misleading, confusing (given there is already a CQC rating for general practices), and contentious.

There is significant scope to improve the publicly available information about general practice and potential priority areas include safety, shared decision making, and workforce climate or culture. In addition, the report recommends the development of a small set of indicators that show what matters most to the public, health care professionals and those accountable for the quality of general practice. This could be led by NICE, working to a strategy set out by the National Quality Board.

Even though some of the challenges facing general practice have been well publicised, the responses to our consultation exercise and discussions during our stakeholder events really brought to life some of the challenges that staff in general practice (and primary care more broadly) are feeling.

One quote from the consultation exercise that particularly resonated with me was this one:

“It seems you can access and engage a few keen GP's in the world of quality improvement but with GP morale at an all-time low it is difficult to attempt to add anything to their workload even if the change is evidenced to deliver quality improvement”

If the main purpose of indicator development is to support improvement, practices need help beyond data. There obviously needs to be sufficient resource for practices to analyse and interpret indicators, and act on the results. In the report we recommend development of a national strategy for improving the quality of general practice and primary care, with progress assessed through the Secretary of State’s annual report. There is a key role for CCGs here, some of which are advanced with respect to analysing data and supporting practices to improve, and some of which definitely are not.

Our review is very much the starting point in developing indicators that paint a credible picture of the quality of care provided by general practices. We were struck by the goodwill shown by those who responded to our consultation and we hope that our findings and recommendations will provide a solid foundation, supported by stakeholders, for changes to the way that indicators are developed and shared with the public and health care professionals.

Emma is a Senior Policy Advisor at the Health Foundation, www.twitter.com/ESpencelayh