Referral rate to outpatient services in London in some practices is triple that in others, report says

BMJ 2012; 345 doi: (Published 05 December 2012) Cite this as: BMJ 2012;345:e8249
  1. Matthew Limb
  1. 1London

General practitioners and commissioners in London must show courage to transform the capital’s primary care, overcome complex challenges, and lift care standards, say health policy researchers.

An analysis by the King’s Fund and Imperial College London says that strong leadership and long term vision are needed to tackle unwarranted variations in the quality of general practice.

Anna Dixon, the fund’s director of policy and one of the authors of the study, said that despite examples of excellent services many GPs were operating in relative isolation and that some premises were no longer fit for purpose.

“The quality of care that Londoners receive is not as consistently good as it should be,” she said.

She said that radical changes were needed, including encouragement of smaller practices to work in networks to provide a greater range of services; more investment in staff; and better use of information and data to understand and limit variations in performance.

The solution is not to industrialise general practice or introduce larger and more homogenised provision, says the study.

The report was commissioned by NHS London to provide a fresh understanding of problems in general practice and suggest possible remedies.1

It says London’s that unique challenges include a population that is very different from the rest of England: “younger, more transient, more ethnically diverse and growing more rapidly.”

Although variation in referral rates is to be expected, outpatient attendances in some London practices are three times as high as in others, which “merits further investigation to avoid the risks of both under- and overuse of specialist and secondary care.”

And whereas on some measures Londoners are healthier than people from other parts of the country, stark inequalities exist within and between the capital’s boroughs.

London has some of the highest levels of deprivation, unemployment, child poverty, and homelessness in England.

Compared with national averages, it has higher rates of low birthweight babies, teenage pregnancy, childhood obesity, HIV infection, serious mental illness, and suicide.

The report says that demographic changes and the “unprecedented financial pressures facing the NHS present a phenomenal challenge” for GPs and commissioners.

London’s greatest public health challenge, it says, is how to close the gap between areas of deprivation and affluence, which underlies the importance of strengthening primary care.

There are significant variations in the quality of care and outcomes achieved between areas and practices, and some variations are unwarranted, says the report.

There are inequalities in prescribing by age, sex, and ethnicity in London, and further investigation of differences in prescribing rates and expenditure is needed, the authors recommend.

One in five GP practices in London is singlehanded, and the ratio of practice staff to GPs is lower than in other parts of England.

Some parts of London have relatively fewer GPs per head of population, and almost 16% of GPs in London are aged over 60 years, compared with 10% nationally.

The authors says that if GPs developed more formal networks of practices they could deliver a greater range of services than is possible when they work on their own; formal networks would also help to reduce professional isolation and facilitate improvements in clinical quality across all practices.

The report says that practices, supported by a wider range of health and social care professionals and with access to specialist advice, should be more proactive in diagnosing and treating chronic conditions.

It also recommends that GPs work more closely with community services providers, hospitals, and social care to achieve better care coordination, preventing unnecessary hospital and care home admissions.

Dixon said that GPs should make better and smarter use of information and technology and redesign care around the different needs of patients, adding: “Achieving change will require courage from leaders working in and with general practice to challenge the status quo and set out a vision that inspires others to believe that change is both necessary and possible.”

Tom Coffey, NHS London’s assistant medical director, said the report came at a pivotal time—as clinical commissioning groups were making plans for the future—and would be used to “identify and develop strategic local change to improve the services communities receive.”


Cite this as: BMJ 2012;345:e8249