A Highland GP on life the universe and anything…

“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.

Update 4.10.2011

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.

Account of attending SPSP Primary Care day

[1] Berger J. A Fortunate Man: the story of a country doctor.London: RCGP; 2005

[2] Des Spence Stop! In the name of love BMJ 2009;338:b1757

[3] Iona Heath. Quality in primary health care: a multidimensional approach to complexity BMJ 2009;338:b1242

[4] Plsek and Greenhalgh The challenge of complexity in health care BMJ.2001; 323: 625-628

[5] Royal College of General Practitioners Curriculum Statement 1: Being a General Practitioner. www.rcgp-curriculum.org.uk

[6] The King’s Fund. Improving the quality of care of patients in general practice. 2011


Comments on: "The Difficulty of Measuring Quality" (4)

  1. From Steve McCabe in Skye: –

    Thanks for this Miles – and I have sympathy with what you say. However, there are two isues for me:-

    (1) I think, as a largely liberal-leaning, middle-class profession, we over-estimate how important the issue of holistic care is to the vast majority of people we see. Most of them do not have this agenda in my view. Rather they are like me with dentists – I go for a check up or because I have a pain, fractured tooth, lost filling, or whatever but all I want them to do it either tell me all is well or fix it. I don’t want them to look for the hidden agenda or delve into my background circumstances.

    (2) We have guidlines from world-renowned organisations like SIGN and NICE which take several years to develop, which are led by experts in their field and which, in the best cases, are based largely on A grade evidence. Yet clinicians continue to ignore them and are never asked to justify why.

    For me quality and safety are inseperable. At the moment we do not have an adequate safety culture in the NHS and avoidable harm continues to happen every day. Airline pilots, on the other hand, have an engrained safety culture – rigorous training and continued development backed up by a strict adherence to check lists and protocols which is why planes crash so seldom. I am not saying we are analagous to pilots but I think we have a lot to learn from their safety culture.

    QOF doesn’t work because it only rewards specific pieces of information without looking at the clinical picture as a hole. Of course there are conditions where a check list or guideline is of little help – but I truly believe these are in the minority. By redesigning QOF to focus on those areas where good clinical evidence exists and deciding, for each of these areas, what are the most important elements of care that these patients should have and then paying only when the bundle is complete, then I think both quality and safety will be significantly improved.

    The enhanced services are a joke, driven in no small part by lobby groups who feel we need an enhanced servcie for MS but not one for, say, rheumatoid disease or inflammatory bowel disease or Parkinson’s disease. They achieve nothing that could not be done through QOF and are little more than an unnecessary distraction in my view. That is why I think they should go and QOF should take up the slack (and the money!).

    Anyway, happy for (and actually really keen on) a genuine debate on these matters as I believe passionately that we could do better.



    • Steve,

      I am in complete agreement re saftey culture and the approch to non-technical error and Team resource Management – all good stuff. I would place all of this in a “competence” group, able to be assessed by testing but not by recording empirical data.

      As for guidelines I have less trust in their robustness even at UK level. I was involved in depression guidelines for NHSH on at least 2 rounds. Good ways of organising evidence but best used as guides rather than prescriptive models, at least for doctors. Looking at the falls work by NICE, level of evidence much less secure and not based in community, nor 1ry prevention. I fear that just because NICE says so people follow it blindly.

      The next problem is complexity. Single pathologies in otherwise healthy individuals are fine but I will attach a slide Martin Wilson sent me yesterday, things are not that straightforward and this is when the holistic comes in. Even if patients are not seeking it it is imperative for us to assess the whole situation to avoid making things worse. That’s when our professional judgement comes in over and above what a specialist nurse can offer.

      • Steve McCabe’s reply: –
        I don’t disagree with you – I am not saying that guidelines are the be all and end all but there are good guidelines out there with a sound evidence base which continue to be ignored with impunity. I just think that is fundamentally wrong – professional freedom does not mean freedom to ignore the evidence.
        Of course, patients don’t fit into nice (no pun intended!) easy boxes and, of course, we need to use all our knowledge and experience to try and offer them the best package of care. But I also believe, even when multiple co-morbidity is present, this can be broken down into each constituent part which can then be addressed according to guidelines and in an evidence-based approach.
        It’s just a different approach I guess – more complicated and time consuming but potentially more rewarding if we get it right.
        A patient’s social and occupational history is important and a good argument for GPs staying in the same practice for many years so that this knowledge becomes ingrained in them but I am more concerned that the evidence shows that only a minority of patients are getting the full package of care when it comes to, say, their heart failure. That then leaves the door wide open for avoidable harm. That’s simply not good enough.



  2. QoF points – nil, Points that matter – full marks!
    Just been discussing with a colleague how she spent over an hour liasing between a patient and care services re patient declining all help. Her trust in her doctor clearly a huge factor in the patients well being.

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