Artisans for cheese please, not healthcare

Prepare for a shock. Smash the rose-tinted spectacles. The Kings Fund’s independent 18-month enquiry Improving the Quality of Care in General Practice found considerable variability in key quality of care domains around England’s GP practices.  What this means for the consumers – you and me – is important.  Some GP practices are terrific trailblazers of integrated, patient-focused care into the new century; others are scarcely more than a 9-5 cottage industry unchanged in 50 years.  These variations are not just unfair to patients.  They reinforce health inequalities, are poor value for money and must not continue.

The panel’s research found that many GPs practised as if they were “autonomous artisans” working in craft-based practices where “the individualistic mentality is at odds with most improvement methods that employ systems-based approaches to learning, delivering and shaping care”.

MAC’s verdict on this is clear: artisans are great for cheese production, not for delivering healthcare.

England needs a real primary-care led NHS, not the gaggle of contracted private businesses we have now which are in many places not very amenable to change or accountability to people who use them.   Primary care providers should be performance managed to achieve quality outcomes and reduce health inequalities.

Our worry is that we aren’t likely to get that with present GP arrangements, even where strong commissioning consortia hit the ground running.  It needs a culture change in GP-land to achieve responsiveness.  Patients should take charge of leading it.

Below are some highlights we’ve drawn from the enquiry’s report that make the case for change.  The whole document, 150+ pages, is worth a serious study together with the research reports commissioned by the enquiry team during its work.  These are available on the Kings Fund site

Diagnosis, referral, access and engagement – could do (a lot) better

Research commissioned by the enquiry found that variations  both within (individual GPs) and between practices were pronounced in key domains like diagnosis (especially acute illnesses), referrals to consultants and giving patients a choice of provider hospital, getting access to the surgery by telephone and advance appointments and for on the day urgent care.

They found that “speed of access appears to be less important to patients than choice of appointment or the ability to see a particular GP” –  which points up the challenge of change to achieve continuity and choice with better access and scale.  Bigger is often better, but not at the risk of impersonality.  New technology and new media, skilfully deployed, can help address this.  Most practices are lagging far behind on this.

A big failing  across many practices is in engaging with patients.  Not only individual involvement in decision making about care, but on the practice level where involvement means including users in decision making about the primary care business itself and its services.  The customers aren’t part of service evaluation and practice governance in most places. That’s at the root of the problem in our view.

The enquiry’s research on patient and public engagement  Quality of Patient Engagement and Involvement in Primary Care makes depressing reading, though there are a couple of wonderful beacons of how things can – and should – be done.  At the moment these beacons are shining in the darkness.

Many GPs don’t understand that involvement has more than one dimension.  But it should be obvious, because as the report spells out:

Listening to and involving patients and the public at a practice level are key to delivering high-quality services.

This is different from involving patients directly in co-creating their health and care for example through personal budgets or shared decision-making.

One standard needed – simply the best

There should be only one standard in general practice  - the best quality possible from both the clinical and patient perspective.   The report lays out what “good” should look like in general practice.  The problem is most patients don’t share this vision because it has never been made clear to them what they should expect as consumers.

The NHS Constitution is a start, of course, but it is far from sufficient.  The public must have access to easy to interpret evidence about performance against standards  that actually mean something to service users, so they can choose and change primary care providers and help to drive up quality by making good choices. Most don’t know “what good looks like” and PCTs have been reluctant to tell them about this. If Mr Lansley’s “information revolution” can change that, he will have done a great service.

Only  six PCTs in the Kings Fund research routinely made comparative performance “scorecard” data available to the public on their websites.  It should be 100% as a matter of routine information provision.

Without access to the right data and an easy way to interpret it, how can customers decide between practices?  Which? does it for consumer goods and holidays, so why should they not do it for GP practices?

A good start would be to break open the locks on the data treasure trove that is NHS Comparators. This remains firmly bolted shut against all but the privileged few NHS insiders, so consumer bodies cannot mine it for results and make scorecards themselves.  It is an intolerable situation in a publicly funded service where the moral owners  - the public – are denied information about how the service for which they pay is performing.  We do this for schools, why not for primary care practices?

Failure regime for practices and practitioners needed – this way to the exit

When helping poorly performing GPs get better doesn’t work, there needs to be a quicker exit strategy.  The Kings Fund enquiry doesn’t really address this.  It should have. During trials last year of GP revalidation, 1 in 10 GPs taking part – and they were keen volunteers – were referred for performance issues.  That doesn’t mean they are unsafe, just that they needed to improve.

Reflecting concerns of the Health Select Committee enquiry about protecting patients from the minority of incompetent doctors, Government has now pledged to speed up the individual revalidation process.  We welcome that because, as the Health Select Committee made abundantly clear:

“the primary purpose of revalidation is to protect the interests of patients”

The  CQC registration of practices regime is due to be implemented by April 2012 and this will  also help weed out the failures where remediation doesn’t help.  Lay people – patients and the public – need to be involved in revalidation and registration processes.

MAC’s view is that where individual or practice performance or conduct cannot or will not improve, clinicians should be removed from the performers list and their patients reallocated to other practices and failing practices should be closed.

What a new deal for service users looks like

The NHS Atlas of Variation in Healthcare published late last year by the Department of Health shows how primary care trusts vary in their care of patients, their costs, and their outcomes.  The GP-led commissioning consortia in England will be the inheritors of this, for good and ill.

The Kings Fund independent enquiry advocates “post-industrial care …. [with] much greater emphasis on teamwork, closer integration between GPs and specialists, and a new deal with patients.” That “new deal” can all be summed up in the now well-worn phrase “Nothing about me without me”.  But until we hammer out what this means at every step of the patient journey and how it is different from what happens in too many practices now, these will remain empty words in too many places.

Involvement and engagement of patients is essential to quality which must permeate the new deal with patients.  The best businesses in primary care understand that already.  For the rest, there need to be persuaders and sanctions to ensure that all of them understand that “measuring performance, improving care standards, and transparent reporting are key features of the way care is provided.”

There is reason to hope that the increasing scale of primary care may have a positive influence on this.  As the report says, “general practice will need to operate at a scale commensurate with the demands placed upon it. There is an urgent need to accelerate the work to establish federations of practices, and to bring isolated practices more formally into larger provider organisations or networks. The advent of GP commissioning will make this a necessity.”

We have no doubt that healthcare in England should become more “post industrial” and open to competition on quality and outcomes, including patient satisfaction.

Internal efforts like revalidation of practitioners and registration of practices are essential to improve quality, but so is the external context in which GPs work.  On this point, we give the last word to Chris Ham in his introduction to the enquiry report:

“the stimulus provided by new market entrants may prove to be just as important, perhaps more so, than the drive to improve quality that comes from within.”

That is one prediction we hope will come to pass, so the artisans can stick to the cheese making.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

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