Quality in primary care

The United Kingdom has led the world in several national policy initiatives to improve the quality of primary care, notably by implementing both nationwide surveys of patient experience and the largest healthcare pay for performance scheme in the world—the Quality and Outcomes Framework. This makes the United Kingdom fertile ground for examining the many uncertainties surrounding these policy initiatives, two of which are examined in the linked papers (doi:10.1136/bmj.g6034, doi:10.1136/bmj.g6423).1 2

Roberts and colleagues used multilevel modelling to explore whether variation in patient experience was due more to individual doctors or to the practices within which they worked.1 The doctors were responsible for 3.5 times more variation than the practices in patients’ experience of communication in the consultation, and 6.5 times more variation in whether or not patients trusted their doctor. In contrast, much more variation existed between practices than between the doctors for four indicators measuring aspects of patient experience that are less under the control of individual practitioners, such as cleanliness of buildings or ease of access.1 This is consistent with the few other studies that have rigorously examined variation in outcome at both individual and institutional level,3 suggesting, for example, that blood pressure measurement for patients with diabetes varies more between …