BMJ 2003;326:457-458 ( 1 March )

Editorials

New contract for general practitioners

A bold initiative to improve quality of care, but implementation will be difficult

News p 465

This week a proposed new contract between the NHS and general practitioners contains an initiative to improve the quality of primary care that is the boldest such proposal on this scale ever attempted anywhere in the world.¹ The proposal spells out 76 quality indicators in 10 clinical domains of care, 56 in organisational areas, four assessing patients' experience, and a number of indicators for additional services. The proposal furthermore sets targets for performance that will be accompanied by increased payments to providers. Like any bold proposal this one offers the promise of a quantum change in performance rather than an incremental one. To get there, however, will require a great deal of work by all involved and may come at the price of other aspects of primary care being left out of this quality framework. The net effect on primary care will therefore depend on how this initiative is implemented and the follow on work of the NHS and general practitioners at building on what works and a willingness to discard or change what does not.

What led to this initiative? There is much evidence that certain aspects of primary care are not being carried out at optimal levelsfor example, the adequate control of blood pressure in people with hypertension and the management of diabetes.² Despite continuing medical education, publication of practice guidelines, and the efforts of professional societies a sizeable gap exists between what can be achieved and what is being achieved. This continuing gap, combined with requests from general practitioners to be provided with more resources to deliver high quality care and to be rewarded for delivering it, led to this new bold proposal. With one mighty leap, the NHS vaults over anything being attempted in the United States, the previous leader in quality improvement initiatives.

Many quality indicators
I like much in this proposal. Firstly, it specifies a large number of specific quality indicators in multiple domains of care and links these to a method of implementation that is likely to achieve real change in performance. Since a sizeable financial incentive is involved there is every reason to expect that general practitioners will change their behaviour in order to try to meet these targets, just as they improved their delivery of cervical smears and childhood immunisations in response to financial incentives. The broad number of quality indicators is also a strength. Much concern exists in the United States that initiatives to improve quality containing only a few indicators promote a situation in which providers concentrate on only those indicators to the exclusion of other aspects of care. The large number of indicators in multiple domains of care in the new proposal will help minimise, but not eliminate, this likelihood.

From my American perspective, another admirable attribute of this proposal is that it was developed by the government that pays for the care working together with the providers to reach agreement on the important aspects of care to perform and be paid for. This is in contradistinction to the approach in the United States, where the providers of care are usually left out of the equation.

Implementing the proposal
Now to look at the hard part. Implementing this proposal is going to be very difficult. Collecting data on the encounters with patients is going to be a huge task that will require comprehensive computerisation of general practices. Since for now the data are to be self reported by the general practitioner, we do not know if the mechanisms proposed to monitor the data (a detailed inspection once every three years) will be enough to overcome the strong financial incentive to present the rosiest picture possible of one's own practice.

As with any programme designed to bring about a certain change, unintended consequences present a worry. Although the number of indicators is broad and the indicators include many of the most important processes known to produce substantial health benefits, even 130 indicators cannot possibly cover all of primary care. What is to become of the care in these "unmeasured" domains? Will it improve, as general practitioners implement systems of care that improve all processes of care, not just the ones measured? Will it remain the same, neither better nor worse? Or will it get worse, as time and resources once devoted to these areas are now redirected towards those areas that are measured and paid for? Such concerns have been raised in the United States associated with the public release of quality information, but empirical data are lacking.

Another and more insidious unintended consequence is the potential for change in the relationship between doctor and patient. Will patients no longer be persons to the general practitioner but rather a series of performance targets to be met? This is a very real possibility, but I do not buy into the argument that improvement in one area of care must come at the expense of another. Patients value both good health outcomes and continuing relationships. The new contract has the promise of a substantial increase in funding for primary care, not merely redirecting payments from one area to another. It is up to general practitioners to respond to this proposal in a way that improves the technical aspects of quality while maintaining the values that have characterised general practice in Britain for generations.

Paul Shekelle, professor of medicine, University of California Los Angeles. 

Greater Los Angeles Veterans Affairs Healthcare System, 11731 Wilshire Boulevard, Los Angeles, CA 90073 USA (shekelle{at}rand.org)

Footnotes

Competing interests: None declared.

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1.	NHS Confederation. GMS contract negotiations. www.nhsconfed.org/gmscontract/ (accessed 24 Feb 2003).
2.	Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care 2001; 10: 152-158[Abstract/Free Full Text].

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© 2003 BMJ Publishing Group Ltd
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