From sins of omission to acts of commissioning: Francis and primary care

Blog post

Published: 26/02/2013

The report of the public inquiry into Mid Staffordshire NHS Foundation Trust has focused our attention on the quality of care provided in hospitals.

The Inquiry was however about the wider NHS system and its ability or otherwise to spot and address failure. Indeed the list of witnesses to the Inquiry underlines the extent to which this wider system includes commissioners, regulators, policy-makers and local general practices.

Robert Francis' analysis of the events at Mid Staffordshire includes an examination of the role of local GPs. General practice is often described as being one of the core strengths of the NHS, offering as it does universal access to local family doctor services.

The vital components of NHS primary care were noted by eminent American academic the late Barbara Starfield as including: enabling continuity of care for individuals and families over time and co-ordinating services for patients across the wider health system.

Robert Francis' analysis of the events at Mid Staffordshire includes an examination of the role of local GPs. Interestingly, the very first indication of problems with care at Stafford Hospital is noted as being a paper prepared in 2001 by the then primary care group (a sort of early clinical commissioning group) for NHS Executive West Midlands.

This suggests that groups of GPs can play an important role in monitoring the quality of care provided by hospitals and others.

However, this one report is conspicuous for being the only point at which primary care galvanised itself to advocate for the patients at Stafford, at least until the Healthcare Commission started its investigation in 2008, when Francis notes that 'a majority of GPs expressed concerns about the quality of care received by their patients.'

Francis paints a picture of GPs who dealt with concerns about patients' hospital care by making contact directly with consultant colleagues.

Indeed, he describes the GPs' role in the Mid Staffordshire case as effectively a sin of omission, but one that is explained by a lack of clarity (at the time) about the connection between commissioning and quality, a reluctance on the part of most GPs to engage actively in practice-based commissioning, and a tendency to focus on work within the practice, not sharing concerns about patient care in forums such as the practice-based commissioning consortium, primary care trust (PCT) or the local medical committee.

Returning to Starfield, we have to ask how continuity and coordination of care will be assured for patients in future, given the role of general practice as our effective 'home' in the NHS system.

The clue to this is in paragraph 7.371 of the Francis report, where he emphasises the role of the GP as co-ordinator of care within a 'continuing relationship' with the patient beyond referral to hospital.

Francis does not leave the GP role here however. He goes on to note that 'they [GPs] will need to take this continuing partnership with their patients seriously if they are to be successful commissioners'.

This represents a profound challenge to general practice, especially at a time when it is struggling under the weight of patient demand, flat funding, and rising expectations of its role.

How will it reorganise itself to ensure that it has the time and information to undertake effective co-ordination of the care of patients with very complex needs? This was the subject of our recent European Summit, supported by KPMG, where we grappled with the challenges facing primary care systems across Europe.

Part of the answer may lie in the development of federations or networks of practices, something that is an increasingly strong feature of primary care in other countries.

For GPs in clinical commissioning groups (CCGs), there is a further challenge to address. In light of the Francis report, they are exhorted to commission for quality of care and to put in place 'enhanced standards' of service for local people.

To do this, they will need accurate and timely information about local services and complaints, and be ready to pursue concerns and account to local people for progress made.

Francis notes optimistically: 'now that the Government's intention is that commissioning groups are to be clinically led, they should be well equipped to assume this responsibility on behalf of all their GPs.' The role of CCGs in monitoring and developing quality of care is a focus of our new research project with The King's Fund.

GPs in Stafford omitted to act collectively to recognise and address the failure of their local hospital. CCGs will have to act to develop and assure the quality of care they provide and commission.

Next time we hear about failings in NHS care, let's hope it is the primary care-based commissioners who are onto the case early on, using their local clinical knowledge and purchasing power to bring about change.

We will be seeking Robert Francis’ views on the issues raised in his report next week, when he is one of the keynote speakers at our annual Health Policy Summit. We will be live-streaming many of the sessions from the event via our Nuffield Trust Live platform, so do join us if you are not there in person.

This blog also appears on the GPonline website

Suggested citation

Smith J (2013) ‘From sins of omission to acts of commissioning: Francis and primary care’. Nuffield Trust comment, 26 February 2013.