Authors
Nick Goodwin Shilpa Ross
Alex Smith
October 2010
The quality of care
in general practice
Capturing opinions from the
front line
Introduction
The Inquiry into the Quality of General Practice in England, commissioned by
The King’s Fund, has collected and examined evidence on the quality of care
and services provided by GPs and other health professionals working in
general practice. The work has focused on key aspects (‘dimensions’) of
general practice, selected by the inquiry panel as representing core areas for
quality improvement.
This paper examines the key findings of an online survey designed by The
King’s Fund to complement the GP inquiry, in order to gain the views of those
working in general practice. The survey sought to gain the opinions of GPs
and other primary care professionals on the extent to which general practice
is currently providing ‘high-quality’ patient care and their reaction to current
approaches to ‘quality improvement’ in general practice. The survey was an
informal one, carried out through the online tool Survey Monkey. As such, it
did not set out to achieve scientific rigour – but instead to offer a snapshot of
health professionals’ views and to indicate areas that might warrant further
investigation.
How was the survey conducted?
The King’s Fund posted the open-access survey on the GP Inquiry website
between mid-December 2009 and the end of March 2010. We recruited
respondents by contacting individuals who had previously signed up for
updates from the Inquiry and through communications targeted at members
of the Royal College of General Practitioners, the NHS Alliance and the Royal
College of Nursing.
Due to the nature of the survey, it would not be appropriate to take the findings
as representative of those working in general practice. However, in capturing a
range of views from the front line, the survey has raised a number of key issues
for further exploration and debate.
1 © The King’s Fund 2010
The quality of care in
general practice
What questions did the survey ask?
The survey was divided into two parts:
n
The first part of the survey asked for opinions about the current quality of care in
general practice, both generally and across the care dimensions selected by the Inquiry.
Specifically, it asked respondents what they thought were the key priorities for quality
improvement in the future.
n
The second part asked about the impact (whether real or potential) of different
methods for quality improvement, and for respondents’ views on how quality could
best be improved in the future. In particular, it asked respondents which approaches
they felt were the most likely, and which the least likely, to improve quality.
How many people completed the survey?
The survey was completed by 843 GPs and other practice-based professionals. Their roles
are shown in Table 1. (Percentages are rounded to one decimal place.)
Table 1 Number and types of respondents from general practice completing the survey*
Role
Number
Per cent
GP partner
569
67
Salaried GP
63
7
GP registrar
16
2
GP locum or sessional GP
29
3
Practice manager
79
9
Nurse employed in general practice
74
9
Other staff member in a GP practice
13
2
*N=843
Results
The quality of care in general practice
For the purposes of the survey, we defined high-quality care in general practice as
‘the delivery of services that improve health outcomes for patients and reflect current
professional knowledge and best practice’. It asked respondents to rate the current level of
quality across different dimensions of care on a 10-point scale, with 10 being the highest
rating of quality. It asked them to do this in terms of the quality provided both in their
own practice and in general practice as a whole.
Figure 1 shows the distribution of findings by each dimension for the whole sample. This
shows that survey respondents rated the performance of their own general practice across
a range of scores, between a low average of 7.9 (out of 10), for tackling inequalities in care,
to a high of 8.6, for the quality of diagnosis and patient engagement during consultations.
Respondents tended to hold slightly more positive views about the quality of care
provided in their own practice than about that of general practice as a whole. In assessing
general practice as a whole, average scores ranged from a low of 7.2, for access to care, to a
high of 7.9, for the quality of diagnosis.
2 © The King’s Fund 2010
The quality of care in
general practice
Figure 1 The quality of various dimensions of care in general practice, as rated by
those in general practice
osis
ment
ons
hips
Diagnosis
t of
ons
Patient engagement
during consultations
erral
Therapeutic relationships
tion
tion
Management of
long-term conditions
care
Referral
Dimension
and
ment
care
Health promotion
and ill health prevention
End-of-life care
care
Prescribing and
medicines management
ties
care
6.5
7.0
7.5
Co-ordination8.5
of care
8.0
9.0
Average score
Access to care
Tackling inequalities
in care
6.5
My practice
7.0
7.5
8.0
8.5
9.0
Average score
General practice as a whole
A key objective of the survey was to test views about which dimensions of care should be
prioritised for improvement. Respondents were asked to tick their top three choices.
Figure 2 shows which dimensions of care respondents felt should be prioritised. As the
figure shows, the two dimensions of care most often chosen as a priority for improvement
were continuity of care (which almost 60 per cent of respondents identified as a priority)
and the management of long-term conditions. Despite the focus on access to care
in recent public debate, this issue came fairly low down the list of priorities and was
My practice
identified by only around 20General
per cent
of respondents. Referral was at bottom of the list,
practice as a whole
with only 10 per cent identifying it as a priority.
The survey also asked respondents to identify the dimensions that should not be prioritised
for improvement, again by indicating their top three choices. As Figure 3 shows, access to
care was most often chosen as the dimension of care that did not need to be prioritised,
even though this dimension received the lowest quality rating of all the dimensions
considered. In contrast, fewer than 1 in 10 respondents identified continuity of care and
3 © The King’s Fund 2010
The quality of care in
general practice
management of long-term conditions as dimensions that should not be prioritised.
End-of-life care was the dimension chosen least often in this part of the survey.
The results of this survey should not be seen as representative, but they do suggest that
those working in general practice would seek to prioritise improvements in continuity
of care over improvements in access to care. This does not mean that access is not an
important consideration, but the findings are consistent with recent indications that
patients, when given a choice, would generally opt for better continuity of care over speed
of access (Gerard et al 2008; Turner et al 2007). The Inquiry’s report on continuity of care
also concluded that continuity of care had been taken for granted for many years, despite
being an important determinant of satisfaction among staff and patients alike (Freeman
and Hughes 2010).
Figure 2 Which dimensions of care should be prioritised?*
60
Percentage
40
20
Co
nt
in
ui
ty
of
lo
ca
ng M
re
-t an
er ag
m e
He
co me
nd n
ill alt
iti t o
-h h
o f
ea pr
lth om ns
o
pr ti
e o
En ven n an
d- tio d
of n
-li
fe
ca
re
Di
P
ag
no
du atie
si
rin nt
s
m
g
co an
ns ag
m
ul em
ed
ta e
ici
tio n
ne Pr
ns t
s esc
m r
an ib
ag ing
e
Ac me and
ce nt
ss
to
ca
re
In
eq
ua
lit
ie
s
re The
la ra
tio p
ns eu
hi tic
ps
Re
fe
rra
l
0
* Respondents (n=672) could indicate up to three dimensions
4 © The King’s Fund 2010
The quality of care in
general practice
Figure 3 Which dimensions of care should not be prioritised?*
60
Percentage
40
20
lit
ie
s
T
re he
la ra
Pa
t
io pe
du tie
ns u
rin nt
hi tic
m
g
ps
co an
ns ag
m
ul em
ed
ta e
ici
tio n
ne Pr
ns t
s esc
m r
an ib
ag ing
em a
en nd
Di t
He
ag
no
ill alt
-h h
si
ea pr
s
lth om
pr oti
e o
lo
ng M ven n an
a
t
-t n
er ag ion d
m e
co me
Co nd nt
nt itio o
f
in
ui ns
ty
of
ca
En
re
dof
-li
fe
ca
re
ua
ra
l
Re
fe
r
eq
In
Ac
ce
ss
to
ca
re
0
* Respondents (n=562) could indicate up to three dimensions
The survey also gave GP respondents the opportunity to provide some ‘free-text’
responses to the question, asking ‘Are there any other aspects of patient care provided
by general practices that you believe require improvements in quality?’. As Figure 4
shows, recurrent themes cited by GPs fell into two main areas: more time spent with
patients, and better care co-ordination. The most cited area in which quality gains
could be made was more time with patients. This was consistent with other non-GP
responses – particularly the need for greater investment in numbers of staff and practice
infrastructure to enable this to happen.
The GPs also cited better co-ordination of care as an important area where quality gains
could be made – especially if barriers in the system could be removed to ensure better coordination of care between professionals and organisations responsible for patient care.
5 © The King’s Fund 2010
The quality of care in
general practice
Figure 4 GP partner responses* on aspects of patient care requiring improvement
in quality
More time for patient care
53
Themes (top 5)
More investment in
resources and/or more GPs
30
Continuity of care (in all
locations and out of hours)
22
Better co-ordination with
other professionals
22
Removal of barriers within
the health care system
22
0
10
20
30
40
50
60
Number of times theme cited
* N=245
Approaches to support quality improvement in general practice
The second part of the survey asked respondents about the impact of different methods
of quality improvement. These included their assessment of the value of:
n
clinical or best practice guidance designed to inform and support those working in
general practice to provide high-quality care
n
pay-for-performance schemes such as the Quality Outcomes Framework (QOF),
QOF+ and local enhanced services
n
the Quality Practice Award an award given to general practices by the Royal College
of General Practitioners in recognition of high-quality patient care provided by all
members of staff in the practice based on a formal assessment
n
revalidation an initiative that assesses whether GPs meet current professional
standards and are fit to practise
n
accreditation a quality improvement process to support the organisational
development of general practice, to demonstrate compliance with the registration
requirements of the Care Quality Commission
n
patient experience surveys that enable information to be gathered about patients and
their experiences of care after they access services
n
balanced scorecards an approach that brings together a basket of performance
measures, in order to assess and monitor performance over time.
The survey also sought views on how quality could best be improved in the future, and
on which of these approaches were the most likely to improve quality, and which the
least likely.
As Figure 5 shows, more than 70 per cent of respondents thought that best practice
guidelines and pay-for-performance mechanisms would have a positive or highly
positive impact. In comparison, only 32 per cent thought this to be the case for practice
accreditation and revalidation schemes, and respondents rated balanced scorecards and
patient experience surveys even lower.
6 © The King’s Fund 2010
The quality of care in
general practice
Cl
in
nt
ex
pe
su rie
rv nc
Ba
ey e
la
s
nc
ed
sc
or
ec
ar
ds
n
at
io
Pa
tie
Re
va
lid
ac
cr
ed
at
io
n
QP
A
st
gu pra
id cti
an ce
ce
Pr
ac
tic
e
ica
la
nd
be
F+
LE
S
Figure 5 What impact do various approaches to quality improvement have?
Approaches to quality improvement
Don’t know
Highly negative impact
Negative impact
Little or no difference
Positive impact
Highly positive impact
The survey also asked respondents to indicate which approaches they thought were the
most, and which the least, effective in improving quality in general practice (see figures
6 and 7), selecting up to three options. Again, the respondents felt that clinical or best
practice guidelines and pay-for-performance mechanisms were likely to have the highest
impact in improving quality, with patient experience surveys, revalidation and balance
scorecards having the least.
It is not clear whether respondents’ views about the impact and effectiveness of patient
experience surveys suggest that those working in general practice do not value the views
of patients, or whether they reflect concerns about the way the surveys are carried out and
the data presented. Either way, if these findings do reflect their views, it gives some cause
for concern.
7 © The King’s Fund 2010
The quality of care in
general practice
Figure 6 What approaches to quality improvement are most effective?*
80
Percentage
60
40
20
n
nt
ex
pe
su rie
rv nc
Ba
ey e
la
s
nc
ed
sc
or
ec
ar
ds
Pa
tie
ita
tio
cr
ed
Ac
QO
be
st
-
pr
ac
tic
e Clin
gu ic
id al
an o
F+
ce r
an
d
LE
S
sc
he
m
Qu
es
al
ity
Fr a
am nd
ew O
or utc
k om
(Q e
OF s
)
Qu
al
i
t
Aw y
ar Pra
d ct
(Q ic
PA e
)
Re
va
lid
at
io
n
0
* N=642
The survey offered respondents the opportunity to comment more generally on
approaches to quality improvement through a free-text question. Most responses to this
question were provided by GP partners. Figure 8 shows the top five themes that they raised.
The responses to the questions about what impact different approaches to quality
improvement might have (see Figures 6 and 7) appeared to put least value on systems
of audit, accreditation and benchmarking. However, in contrast, the free-text responses
from GP partners suggested that practitioners valued these approaches when they were
undertaken by the professionals themselves.
The GP partners who completed the free-text option most commonly cited the need for:
n
learning opportunities
n
continuing professional development
n
the time and ability to use data to undertake internal peer review and local audit.
These themes also emerged strongly in the free-text responses provided by other GPs and
practice nurses.
A final key theme to emerge was the plea for protected time to value and undertake
such activities, enabling professionals to take stock and reflect on the quality of care
they provide.
8 © The King’s Fund 2010
The quality of care in
general practice
Figure 7 What approaches to quality improvement are least effective?*
60
Percentage
40
20
al
Aw ity
ar Pra
QO
d ct
(Q ic
F+
PA e
an
)
d
LE
S
sc
he
m
be
es
st
-p
ra
ct
ice C
gu linic
id al
Qu
an o
al
ce r
ity
Fr a
am nd
ew O
or utc
k om
(Q e
OF s
)
n
Qu
Ac
cr
ed
ita
tio
ar
ds
sc
or
ec
ed
Ba
la
nc
Pa
tie
nt
ex
pe
su rie
rv nc
ey e
s
Re
va
lid
at
io
n
0
* N=647
Figure 8 GP partner responses* on other effective approaches to quality improvement
in general practice
Learning and continuing
professional development
51
36
Themes (top 5)
Auditing
Peer review and feedback
15
Collaboration across
boundaries
14
13
Practice-based commissioning
0
10
20
30
40
Number of times theme cited
* N=242
9 © The King’s Fund 2010
50
60
The quality of care in
general practice
Discussion
This survey was conducted to engage frontline professionals in general practice in order
to gain a snapshot of their views about the quality of care that they provide. It captured
the opinions of some 843 individuals working in general practice. Although it cannot
claim to be representative of the views of general practice as a whole, it does indicate
some interesting findings and raise important questions for debate.
10 © The King’s Fund 2010
n
When asked how many GP practices in England provided high-quality care overall, the
average score was 82.5 per cent. Is this rating something that the profession as a whole
should be proud of, or does it suggest complacency? To what extent does this suggest
that a significant minority of practices are failing to achieve the minimum standards
that one would expect?
n
The survey suggested that when it comes to quality improvement, continuity of care
(in the sense of involving patients in decision-making and helping them to navigate
access to other health services) may be a more important priority than access to care
(in terms of ease of access to practices and convenience of appointment times). Is this
really the case – and, if so, is the current political debate focusing on the wrong issue
by emphasising the issue of access?
n
The majority of GPs who responded to the survey felt that quality would be most
improved through being able to devote more time to patient care, linked to greater
investment in practice infrastructure. To what extent should the focus on investment
be linked to developing and extending the staff, skill-mix and infrastructure within GP
practices, compared with developing better co-ordinated networks of care provision
between GP practices and other providers of primary, community, secondary and
social care?
n
Does the reported view that patient experience surveys lack impact and effectiveness
suggest that those working in general practice do not value the views of patients, or
does it indicate that they distrust the way the data on patient experience is collected?
Either way, should these findings give cause for concern?
n
What is the right balance of levers and incentives to support general practice in
providing the best possible care? Is the Quality Outcomes Framework really the
most important tool for quality improvement, or do the findings suggest a general
unwillingness to embrace or trust other forms of quality improvement initiatives, such
as revalidation and accreditation?
n
The findings indicate that those working in general practice have an appetite for being
proactive in quality improvement – for example, through education, professional
development and peer review. How can the system provide the time and headspace to
enable this?
The quality of care in
general practice
References
Freeman G, Hughes J (2010). Continuity of Care and the Patient Experience [online].
The King’s Fund website. Available at: www.kingsfund.org.uk/current_projects/gp_
inquiry/dimensions_of_care/continuity_of_care.html (accessed on 22 June 2010).
Gerard K, Salisbury C, Street D, Pope C, Baxter H (2008). ‘Is fast access to general practice
all that should matter?: a discrete choice experiment of patients’ preferences’. Journal of
Health Services Research and Policy, vol 13 (2), pp 3–10.
Turner D, Tarrant C, Windridge K, Bryan S, Boulton M, Freeman G, Baker R (2007).
‘Do patients value continuity of care in general practice?: an investigation using stated
preference discrete choice experiments’. Journal of Health Services Research and Policy, vol
12 (3), pp 132–37.
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