Edward Ng: Quality assessments in general practice—have we gone too far?

ed_ngUK general practice receives an unprecedented level of scrutiny to verify that quality is maintained. We have the Quality and Outcomes Framework (QOF) to incentivise GPs to provide better quality care; we have NHS England Area Team visits for contract breaches; we have Care Quality Commission (CQC) inspections; we have appraisals and revalidation; and, depending on the clinical commissioning group (CCG), there may well be local assessments for quality.

At the same time, GP morale is widely reported to be plummeting, with a third of GPs considering retirement in the next five years, many considering leaving the UK, and around 30% of GP training positions unfilled after the first round of recruitment. While the reasons for plummeting morale are multifactorial and complex, the rise and rise of quality assessments is likely to be an important factor. There is certainly widespread discontent with our various inspections, and the Royal College of General Practitioners (RCGP) council has called for the suspension of CQC inspections.

Quality inspections are certainly not confined to GPs and GP practices. Our GP trainees have a plethora of assessments for better triangulation of GP competencies, while secondary trusts have four hour waiting targets for emergency departments and 18 week outpatient targets, among many other measures. Assessment measures are also found outside of medicine: schools have Ofsted inspections; there is Ofgem, Ofwat, Ofcom, and numerous other regulators. It seems that in the UK we like to measure for assurance and to demonstrate the efficient use of public funds.

We have had QOF for 10 years. But what is the evidence of its benefits? Langdown and Peckham and Gillam et al showed that the impact of QOF has been modest. On the other hand, there are concerns about the possible unintended consequences of the scheme, for example, will activities that are not incentivised not be practised so often and therefore not see as many successful results? Is GP training best served by a multitude of trainee assessments? What is the evidence that these assessments drive up standards?

We must also ask questions about other assessments too. CQC inspections of GP practices (247 published by 11 April 2015) showed that 4% were “inadequate,” 11% “required improvement,” but 85% were “good” or “outstanding.” While we need to know about the 15% of “inadequate” and “requires improvement” so that the standards of these practices can be raised, it comes at the cost of handcuffing the other 85% with the additional burden. Furthermore, the Area Teams and possibly CCGs (depending on the local setup) also carry out inspections at practices. Why are practices not having single, unified inspections instead?

All interventions have the potential of helping and harming. Through quality assessments in general practice, we try to reassure the public and each other that we have good doctors, good practices, and that we’re delivering the best care possible with the available public funds. The key, however, is in getting the balance right.

The unintended consequences of over-assessment include worsening GP morale and the focussing of attention solely onto that which is being assessed. As GPs are very busy, an inevitable consequence is that the areas which are not assessed get deprioritised or ignored. We seem to have lost sight of the big picture: being a GP is not really about fulfilling a list of competencies; a good practice is not really about fulfilling a check list of quality assured areas or domains; and good patient care is not really about GPs meeting QOF targets. If we can truly measure professionalism then we can forget all other measures. The converse is not the case—we cannot deliver greater professionalism by having lots of measures. It seems to me that in having numerous surrogate measures for quality assurance, we diminish the importance of autonomous professional pride as the main driver for quality improvement.

I don’t claim to have all the answers. But I would like to propose some ideas for debate. While I acknowledge that the public needs reassurance that problems can be detected and resolved, the checking must not come at the cost of hampering the great majority. This principle applies to GP training, GPs, and GP practices. I am proposing a set of ideas, which are meant to provide direction for improving assessments:

1) I propose a two tiered regime, the standard and aspirational assessment. The standard is exactly what happens now, so no GP or practice would have a greater burden than they do currently. On the other hand, the GPs or practices which demonstrate quality and trust should be moved to the aspirational tier where assessments, if they occur at all, are minimal and very light touch. There is a precedent for this in Ofsted, which has proposed a light touch regime for good schools. When a practice has demonstrated trustworthiness and quality it can move from standard to aspirational, and, conversely, whenever trust is lost or quality questioned, then the practice/ GP moves back to the standard tier.

2) Inspections should be unified whenever possible. An example would be a combined inspection for the CQC, Area Team, and CCG. Practices would then face a greatly reduced assessment burden.

3) Assessments need to be much more holistic and much less of a checklist.

It is time for further debate . . .

Dr Edward Ng has been a GP for 23 years. He has a strong interest in GP training. He supports primary care quality as a clinical lead for his CCG.

Conflicts of interest:
I have read and understood BMJ policy on declaration of interests and declare the following interests:
• I am a GP partner in a GP practice
• I am a GP trainer
• I am an examiner for RCGP
• I am the clinical lead in primary care quality for Birmingham CrossCity CCG

The opinions I have expressed are my own personal views and do not reflect the position of any organisation I am affiliated with.