Who’s complacent now? The King’s Fund on general practice

The UK healthcare think tank the King’s Fund has just published the report of its independent inquiry into the quality of care in general practice (BMJ 2011;342:d1833, doi:10.1136/bmj.d1833). At the start of the inquiry, back in 2009, the fund commissioned a number of research and discussion papers that go a long way towards setting out the immense complexity of measuring quality within the increasingly chaotic context of today’s NHS. It is therefore disappointing to discover that the final report is somewhat superficial. However, not the least of its contributions may well turn out to be the way it manages to underline, albeit unintentionally, how intensely difficult it is to undertake the general practice care of patients day in and day out. For this reader, the report achieves this in three different ways: by presenting out of date scientific evidence, by fudging the discussion of continuity of care, and by the politically correct pretence that all patients are reasonable.

Every day, general practitioners face the challenge of keeping up with developments in biomedical science across the entire range of disease. This is an almost impossible task but remains a professional responsibility. The inherent problem in guidelines and payment for performance is that, because they are based on yesterday’s evidence rather than today’s, they tempt doctors to stop reading and thinking. Figure 12 of the King’s Fund report uses data from the Quality and Outcomes Framework (QOF), the NHS’s system for rewarding GPs for good practice, to show the “percentage of patients with diabetes in whom the last HbA_1c is 7 or less in the previous 15 months by PCT [primary care trust], 2009/10,” clearly implying that achieving this target is a marker of quality. Unfortunately, evidence is now mounting (most recently in the New England Journal of Medicine (2011;364:818-28, doi:10.1056/NEJMoa1006524)) that intensive glycaemic control in type 2 diabetes increases mortality. The King’s Fund independent panel should have been aware of this.

George Freeman, emeritus professor of general practice at Imperial College London, was the lead author charged with preparing the inquiry’s research paper on “continuity of care and the patient experience” (www.kingsfund.org.uk/document.rm?id=8712). At the launch of the main report on 24 March he commended it for acknowledging the importance of continuity of care in general practice but noted with regret the failure to include any reference to continuity in the recommendations. GPs learn very quickly from experience the importance of continuity of care, both because it is highly valued by patients—and particularly by those with the most serious health problems—but also because knowing the patient will usually make diagnosis easier. No one should be surprised that the removal of the last vestiges of continuity of care out of hours, with the changes to the GP contract in 2004, has led to an increase in out of hours emergency admissions to hospital. When a patient is known, it is very much easier to judge the seriousness of his or her condition. The doctor will know whether this is a patient who calls often or almost never and can calibrate a response accordingly. Without these important benefits of continuity of care, the doctor must put safety first; and too often, in the middle of the night, in a strange house, this means arranging an admission. Successive policy initiatives have undermined continuity of care, and GPs have colluded to a variable extent. Beyond the issue of out of hours care, other initiatives include the pressure on practices to become larger, and financially penalising those that take on new partners. This perverse combination means that more and more practices are now staffed by salaried doctors who are much less likely to have a long term commitment to the practice and its patients. The inquiry report avoids tackling this difficult conundrum, which troubles doctors and patients on a daily basis, while making recommendations likely to accelerate current trends. This is a fudge.

As has become standard in policy documents, patients are presented as units of health need, indistinguishable but for their medical histories. They are assumed to be uniformly rational and committed to making decisions designed to promote their health, only to be obstructed by those they encounter working in the NHS: in this case, their GPs. This is a dangerous and oddly pervasive fiction. In the GP’s consulting room patients could not be more different from each other. Furthermore, each episode of illness is different, and each manifestation of disease differs from person to person. I can find no evidence of any understanding that patients can also be abusive, manipulative, and self destructive. The King’s Fund should not forget Rebecca West’s insight, recorded in her epic account of a journey through Yugoslavia, Black Lamb and Grey Falcon: “Human beings are not reasonable, and do not to any decisive degree prefer the agreeable to the disagreeable. Only part of us is sane: only part of us loves pleasure and the longer day of happiness, wants to live to our nineties and die in peace, in a house that we built, that shall shelter those that come after us. The other half of us is nearly mad. It prefers the disagreeable to the agreeable, loves pain and its darker night despair, and wants to die in a catastrophe that will set back life to its beginnings and leave nothing of our house save its blackened foundations.”

The principal conclusion of the King’s Fund inquiry is that “the majority of care provided by general practice is good. However, there are wide variations in performance and gaps in the quality of care that suggest there is significant scope and opportunity for improvement.” In any discipline or institution committed to learning from both science and experience, there must always be scope and opportunity for improvement. It is clear that this applies no less to the King’s Fund than it does to general practice.