The new coalition government is embarking on one of the most radical reform programmes that the NHS has ever seen. Strategic health authorities will be phased out and the role and power of PCTs will be considerably downsized. The NHS will be given new leadership in the form of an independent board while commissioning - and responsibility for the £80 billion budget that comes with this - will be devolved to GPs.
General practice lies at the heart of the coalition’s plans. The flagship policy of GP-led commissioning will transfer real budgets to groups of practices and signals political support for change towards the creation of larger GP-led clinical collectives with more direct accountability for ensuring that high-quality and cost-effective care is delivered to local communities.
Even before these changes, general practice was bracing itself for significant changes to its way of working. There was already considerable momentum for reducing the numbers of small practices through some form of enforced movement to federated models of working.
The assumption behind this is that it would lead to better quality and cost-effective care, as well as enabling a shift of care from hospital to community settings. The regulatory environment is further cementing this by professionalising general practice via GP revalidation, practice accreditation and changes to the national GP contract. The relative performance of practices is also becoming ever more transparent through the quality and outcomes framework (QOF) and a greater emphasis on patient reported outcomes.
General practice will have to evolve rapidly to embrace this process. The modernization agenda for general practice will be transformative - moving it from a cottage industry to a post-industrial model of care which emphasises standardised care, performance measurement and transparent reporting.
How to judge what high quality general practice looks like is a central question here, and one which lies at the heart of the King’s Fund’s independent inquiry into the quality of general practice, chaired by Sir Ian Kennedy, which will report towards the end of this year. A key emphasis of the inquiry has been to understand whether and how quality can be measured and what approaches really lead to sustained quality improvement. A common finding to emerge is that existing quality measures (such as QOF indicators) are important levers for improving quality, yet do not capture the true essence of high quality care. For example, important issues such as the quality of care co-ordination and continuity of care are left unmeasured and undervalued.
Whilst the coalition government suggests that ‘outcome’ measures are best, and that any targets must have ‘clinical validity’ or be rejected, the inquiry will show that it would be a mistake to rule out other measures of care quality. In particular, a key test of GP-led commissioning will be whether it actively seeks to embrace and monitor the quality of care within its own patch.
As the inquiry begins to assess the evidence it has commissioned it will begin to make a judgement on what the future of general practice should look like. For sure, GP-led commissioning has great potential to support this by developing collective incentives for providing higher-quality primary care. However, the transition to the new arrangements will need to be managed effectively to ensure that the focus on quality improvement and rigorous financial control lies at the heart of what they do.
Dr Nick Goodwin is project director of The King’s Fund’s Inquiry into general practice
