How to assess quality in primary careBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5950 (Published 06 November 2015) Cite this as: BMJ 2015;351:h5950
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On the whole most GPs probably accept the usefulness of comparison data and quality indicators in questioning their own practice. It is important that they are deemed to be robust, reliable and from a trustworthy source. In terms of providing patients with this data, it needs to be in a form that they want and can usefully understand. In choosing a practice, the Health Foundation admits in its report that patients firstly may not have a choice of practice and if they do they either go to the nearest or on the recommendation of a partner. GPs know that patients often leave it to the last minute to register when they become ill or urgently need medication and usually join on the recommendation of a relative or neighbour. The report states that when questioned patients say that they want more information but it has yet to be shown that they will actually access it. Providing certain types of information to patients may have unforeseen consequences. For example, they may choose a practice that is high prescribing on antibiotics, and new high cost drugs, and has a high referral rate, because this is what they feel will meet their needs. From patient surveys they seem to be more interested in more basic issues to do with being able to park the car, getting through on the phone to make an appointment, and whether the doctor is interested, listens and has a caring, empathetic attitude.
Comparison data seems to be used to encourage all GPs to gravitate to the mean in an amorphous, homogeneous mass, even if this is overall a less desirable state. Most GPs still aspire to be excellent even if this is aberrant from the average.
Competing interests: No competing interests
In trying to assess quality in primary care we firmly believe that a paradigm shift in our thinking is needed. One way to do this would be to include positive health indicators in any quality assessment tool.(1,2). Such indicators could be used to change our perspective away from one mainly focusing on sickness and towards one that has more of a focus on health. The ultimate goal of any quality assurance system should be to increase health gain for the population served by the practice.
Health promoting general practice is the gold standard for health promotion, and in order to become a health promoting practice, staff must undertake a commitment to fulfil the following three conditions:
1. create a healthy working environment;
2. integrate health promotion into practice activities; and
3. establish alliances with other relevant institutions and groups within the community.(3,4)
We believe that general practice has a key role to play in promoting health both at an individual and community level. However, for effectiveness it is important that there is action in other settings as well, including: schools, colleges and higher education; workplaces; and hospitals. Public health departments have important roles in facilitating and coordinating such activities.
There are challenges and opportunities for all those working to promote health in general practice. Some of the challenges are: balancing the needs of individuals with the needs of the population; high workload; and capacity and resourcing. These may to a certain extent, explain why a recent scoping study found that “While many GPs see health promotion as an integral part of practice, GPs generally do not take a population approach but focus on individual patients.”(5)
Having adequate capacity and sufficient resources are crucial issues in relation to developing high quality health outcomes. However, there is growing evidence that funding in general practice is lower than current needs and in some parts of the country there are severe shortages of GPs.(6-10) Furthermore, and critical for population health is the finding that under-doctored areas tend to be those with the greatest health needs.(6) In conclusion, it is important to note that however good our doctors and nurses are, if we do not equip or support them properly to deliver quality work, they will not be able to do so.
1) Catford JC. Positive health indicators – towards a new information base for health promotion. Community Medicine. 1983; 5: 125-132.
2) Watson MC and Watson EC, 2013. Premature deaths across England. Time to focus on positive health indicators to reduce health inequalities BMJ 2013;347:f4210.
3) Baric L. Health Promotion and Health Education in Practice. Module 2. The organisational model. Altrincham: Barns Publications, 1994.
4) Watson, M., Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
5) Peckham S, Falconer J, Gillam S, Hann A, Kendall S, Nanchahal K, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Health Serv Deliv Res 2015;3(29).
6) Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. Journal of Health Services Research & Policy. 2010. 15(1): 28–35.
7) Centre for Workforce Intelligence. In-depth review of the general practitioner workforce. 2014. [viewed 8 November 2015]. Available from: http://www.cfwi.org.uk/publications/in-depth-review-of-the-gp-workforce
8) NHS GP Taskforce. Securing the future GP workforce—delivering the mandate on GP expansion. 2014. [viewed 8 November 2015]. Available from: https://hee.nhs.uk/2014/07/22/gp-taskforce-report/
9) Limb M. Increase GP trainees by 450 a year to avoid crisis, says taskforce. BMJ2014;349:g4799.
10) Royal College of General Practitioners. New league table reveals GP shortages across England, as patients set to wait week or more to see family doctor on 67m occasions. Publication date: 08 February 2015. [viewed 8 November 2015]. Available from: http://www.rcgp.org.uk/news/2015/february/new-league-table-reveals-gp-sh...
Competing interests: No competing interests