“To date he must have treated well over 100,000 cases. This would seem a ‘good’ record. Would it be less good if he had only treated 10,000? Supposing he is an intelligent but careless doctor – how much must he forfeit from his record for treating one case, ten cases, a hundred cases carelessly? Supposing that he is an intelligent and unusually dedicated doctor, how much must be added to his record? What would his bonus be?”(1)
This quote, from John Berger’s description of an English rural GP working in the 1960s, shows that the struggle to measure quality in General Practice is not new.
With increasing use of computers, we can now collect more data on quality than ever before. As a result a large proportion of practice income now depends on achievement under the2004 Quality and Outcome Framework of the GMS contract.
Research suggests that this contract has reduced inequality across the country, but many fear its consequences.(2) For example, Iona Heath raised concerns that the contract only measures “vertically oriented care” i.e. the care of an individual disease entity rather than the whole person experience, including the effects of the wider environment.(3)
In addition, other non-contract measures have been developed, such as the Quality Practice Award and Practice Accreditation. These do provide a wider appraisal of practice organisational structure, but even they rely on empirical evidence that has been defined and agreed by the profession as being markers for quality care.
Thus the current focus is on actions, organisational structures, and clearly defined outcomes.
Yet when considering the reality of the cases we face in General Practice, it is quickly clear that much more than the above is needed to guide our actions. For instance, a case of ‘irritable bowel syndrome’ might in reality be a mother struggling to cope, who could also be an unhappy employee, possibly concerned about a worrying family history of cancer. ..and so on. Suddenly the doctor finds there is “insufficient agreement and certainty to make the choice of the next step obvious”.
In these situations guidelines and care pathways may inform action but they will not direct it. The complexity of the case may mean that the evidence is contradictory or uncertain and there may be more than one acceptable and justifiable course of action(4) .
Suddenly new attributes become important such as ethical reasoning, emotional literacy, imagination, perception and judgement; none of which has a validated assessment tool.
The profession must widen the definition of quality to something far greater than the audit of empirical evidence. To ensure we are providing high quality care, we will need to ensure our skills exceed the basic competencies for the profession(5) and that the other more complex virtues continue to be valued and cherished.
I was pleased to see these concepts repeated in the BJGP editorial in the October issue, reporting on the King’s Fund report (6)on quality in General Practice. Notably:-
- They were unable to develop quality indicators for key aspects of care
- No tools exist to capture quality of care to patients with multiple morbidity (29% of those attending a GP)
- QoF only covers 10%of GP activity
- Far more scope for improvemnt might be found by extending our reflective practices such as Significant event Analysis and Balint Groups.
- Other words used were “spirit,” “passion,” “commitment,” “complexity”and “love”
- We shouldn’t forget we have an “international reputation for excellence” but we must still do better.
 Berger J. A Fortunate Man: the story of a country doctor.London: RCGP; 2005
 Des Spence Stop! In the name of love BMJ 2009;338:b1757
 Iona Heath. Quality in primary health care: a multidimensional approach to complexity BMJ 2009;338:b1242
 Plsek and Greenhalgh The challenge of complexity in health care BMJ.2001; 323: 625-628
 Royal College of General Practitioners Curriculum Statement 1: Being a General Practitioner. www.rcgp-curriculum.org.uk
 The King’s Fund. Improving the quality of care of patients in general practice. 2011