Quality and safety: reflecting on the state of general practice

With most GP practices shown in a new report to provide good or outstanding care, Charlotte Paddison reflects on what should happen next in primary care and what can impact on its quality.

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Published: 26/09/2017

The vast majority of English GP practices provide good or outstanding care, according to inspections of 7,365 practices in a new report by the Care Quality Commission. This is welcome news not just for patients, but also for GPs working hard at the front line.

Perhaps most impressive is evidence of continual quality improvement, with the proportion of practices rated as “good” rising from 79 per cent in a first inspection to 86 per cent in the second. This means better quality and safer care for 3.4 million people. Such improvement is all the more impressive because of very real workforce and funding pressures, which is testament to GP professionalism and a strong commitment to high-quality care for patients.

But more work is needed to ensure access to the best primary care for all patients, and pockets of poor care remain. One in 10 practices needs to improve, and in 147 practices overall care was rated as “inadequate". 

Responding to the challenge

The challenge for primary care now is twofold.  

First, how to improve care for practices that are struggling, and second, how best to sustain momentum for improving quality in GP surgeries. 

Closing the gap between the ‘best’ and the ‘worst’

Improving quality of care for all patients in primary care means bringing poorer practices closer to the standards set by the best ones. Learning from practices that improved after an initial “inadequate“ rating highlights the importance of:

  • acknowledging there is a problem (a necessary precursor of motivation for change)
  • resolving governance issues, ensuring consistent policies and clear lines of responsibility
  • improving systems for patient record-keeping and clinical audits
  • leadership for a positive cultural shift within the practice.

Some practices can be reluctant to ‘own’ a problem, with others unable to address long-standing dysfunctional relationships internally. Both factors are associated with failing to improve poorly performing practices.  

In contrast, access to peer support – such as via the Royal College of General Practitioners and NHS England, or through working with other practices within a larger federation – can help practices improve the quality of care they provide.

Sustaining improvements in quality of care

Partner GPs are often very active and invested in leadership within their practice, playing an instrumental role in driving improvements in care quality. Leadership for quality improvement may be challenged by a loss of partner GPs, with a 400 per cent increase in the number of salaried GPs from 2003 to 2012. Greater use of multidisciplinary teams, including a leadership role for nurses in quality improvement, for example, could help in sustaining continuous quality improvement within primary care.

Do we need a greater focus on safety in primary care?

Safe primary care is important. In the first CQC inspection, 27 per cent of practices were rated as “requires improvement” and 6 per cent as “inadequate” for safety, which is concerning. But there is also evidence that GP surgeries acted on safety concerns. Indeed, looking across the five measures inspected, safety is the one where the most positive change took place. 

But there is more work to be done, and it is a priority. As well as having the right systems and processes, we also need the right mindset. This means a practice culture where safety is at the top of the priority list – and where people can speak up quickly and without fear if something is not right.

Quality in primary care – is bigger always better?

Current health policy emphasises the benefits of upscaling primary care. Larger practices may, for example, have improved back office functions, better systems for identifying poor care, and greater capacity and flexibility to respond when poor care becomes apparent. But practice size is only part of the story.

Upscaling does not automatically result in higher quality of GP care, as we’ve emphasised before. Other factors – such as good leadership, a committed practice manager, and proactively responding to patient needs – are also important.

Smaller GP surgeries were more likely to receive an “inadequate” rating than larger surgeries, but we shouldn’t pigeon hole small practices as poor practices. Many provide excellent care, with high levels of continuity and a responsive, patient-centred approach. Rural practices, for instance, are by nature likelier to be smaller, and GPs in rural areas were more likely to get outstanding ratings than urban counterparts.

A greater role for academic primary care?

Improving quality and safety in primary care needs strategies that are grounded in the messy realities of frontline care, drawing on the best scientific evidence. This means building stronger bridges between the swampy lowlands and the ivory tower, and drawing on lessons already learned about the challenges of improving quality in health care. We also need better national data on activity in primary care.

The big picture for general practice is positive. In inspections of more than 7,000 GP surgeries, nine out of 10 surgeries offered care that was good or outstanding, which is a testament to hardworking GP surgeries across the country. But there is more we can – and should – do to improve patient safety.

*A version of this post originally appeared in GP Online on 25 September 2017.

Suggested citation

Paddison, C. (2017) "Quality and safety: Reflecting on the state of general practice" Nuffield Trust comment www.nuffieldtrust.org.uk/news-item/quality-and-safety-reflecting-on-the-state-of-general-practice

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