Better value primary care is needed now more than everBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4944 (Published 10 November 2017) Cite this as: BMJ 2017;359:j4944
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Watson and colleagues make a convincing case for basing primary care's priorities on the idea of value, and although driving the process with evidence based policy and investment are fundamental, I would like to encourage greater use of data on the outcomes of practice populations. How can you judge value without measuring outcomes? The misleadingly entitled quality and outcomes framework tends to measure what practices have done, rather than what they have achieved. Take the example of mild hypertension used in the paper. The balance between benefits and harms for mild hypertension should not be assumed by practices to mean that policies to detect and manage all hypertension are no longer needed. Observational studies show an association between population premature (BMJ Open 2016;6: e009981. doi:10.1136/ bmjopen-2015-009981) and cardiovascular (PLos One. 2012. 7(10): e47800.) mortality. A higher proportion of the practice population included on hypertension registers is associated with lower mortality, suggesting that undetected hypertension remains responsible for may potentially unavoidable deaths in England.
As Watson and colleagues point out, health checks are unlikely to be the solution to this problem. Twenty-six years ago Tudor Hart showed how general practitioner delivered continuity, case finding and audit succeeded in identifying people with increased cardiovascular risk; he was even able to report an associated decline in mortality. In our registered list system, almost everyone will eventually consult a general practitioner, creating the classic opportunity to detect hypertension. Of course, both time in consultations and continuity are under threat as the pressure of general practice has grown whilst the numbers of general practitioners has not kept pace. Observational studies have shown an association between the supply of family doctors and population mortality in the United States (Milbank Q 2005;359:457-502.). The same association can now be found in English general practice (BMJ Open 2016;6: e009981. doi:10.1136/ bmjopen-2015-009981), and an association between GP numbers and quality of life in the population has been shown in recent years (Centre for Health Economics, University of York. CHE Research Paper 20, October 2006). Practices in under-doctored areas might consider monitoring their outcomes to inform and pressure policymakers to increase the resourcing of primary care.
A practice or group of practices with, say, 20,000 patients, could readily monitor data on fatal and non-fatal cardiovascular outcomes; with information on the practice population characteristics and the ability to compare data with other practices, it would become possible to inform local clinical policies with data on local outcomes. Perhaps patients could use the data as well to help them make more informed assessments of the balance of benefits and harms for their own treatment decisions.
Competing interests: No competing interests