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Daily Telegraph: Variation across General Practice – choose your GP carefully

March 8, 2013

My article in today’s Daily Telegraph, and the accompanying piece by Stephen Adams.

(Those who know a little about the press will understand that the author doesn’t choose the title used by the paper – my original title is above.)

 

Public, patients and doctors alike may want to read the evidence and research that underpin the reality that – whilst many, many doctors and nurses deliver excellence in General Practice – there is significant, substantial, measurable variance in quality. This variance costs lives, and is why doctors always choose carefully who treats them. Below is my original, full-length article with links to the independent research.


When doctors or their families need NHS care they choose carefully who treats them. They know that the NHS logo, far from being a mark of uniform excellence, is actually a warning sign that says “beware – varying quality ahead”.

This was highlighted in the Daily Telegraph last week, up to two-thirds of doctors and nurses at some hospitals would not recommend that their family and friends are treated where they work. It is worth contrasting this with British Airways – an industry with excellent quality and safety – where 100 percent of pilots say they would be absolutely happy to be flown by their colleagues.

The Francis Report and subsequent investigations into fourteen hospitals with excess mortality rates have brought the variation in quality across NHS hospitals into stark reality: it really does make a difference where you go and who treats you.

However, despite this very real and significant variation across the NHS, it has been impossible for the public to know the quality of their local hospital or to make simple comparisons with others nearby.

David Cameron’s Friends and Family Test (FFT) will finally provide meaningful comparative metrics that will enable people to make informed choices about who treats them. Importantly, the evidence is now absolutely clear that patient feedback is an accurate way to assess the quality of care: real-time, continuous feedback can be the “smoke-detector of patient safety”, highlighting falling standards before they lead to tragedies such as the ones in Mid-Staffordshire, Morecambe Bay and Worcester. Indeed, unusually for the politics of healthcare, there is cross-party support: when Health Secretary in the last Government Andy Burnham said that he would create a “TripAdvisor style comparison site”.

Research from London’s Imperial College and Harvard shows that simple ratings and reviews delivered in formats familiar to the public and standard across the web will provide a new way to monitor safety, identify quality and help the public choose great care.

Starting next month, the Friends and Family Test will monitor hospital care. Having worked as a doctor in the NHS for nearly twenty years, I believe this should rapidly be extended to our whole healthcare system, starting with general practice.

Whilst the doctors’ unions might blithely claim that “the majority of patients are happy”, the independent, unbiased science and research shows a different, far more worrying, reality.

Variation in the quality of general practice is “significant and unexplained” according to the King’s Fund: “there are wide variations in performance and gaps in the quality of care that suggest there is significant opportunity for improvement”.

In a 2010 report the National Audit Office identified that, across primary care, there was almost a four-fold variation in the urgent cancer referral rate – with the National Cancer Intelligence Network estimating that if patients were diagnosed at the same earlier stage as they are in other countries up to 10,000 deaths could be avoided every year: “it’s clear from these data that there’s variation that needs to be addressed” (the associate director of the National Cancer Intelligence Network’s clinical outcomes programme).

The NHS’ own Atlas of Variation makes it clear that for many common conditions such as diabetes, the care patients receive varies widely, with up to five-fold differences in the rates of amputation or death: “…the indicators in this Diabetes Atlas clearly demonstrate there is considerable variation in both the processes and outcomes of care. Although it is acknowledged that some areas are providing very good care for people with diabetes, sadly, there are a substantial number of patients who are not receiving all of the nine basic care processes designed to identify treatable risks and early complications of diabetes” (Dr Rowan Hillson MBE, National Clinical Director for Diabetes).
Thus some patients are literally gambling with their life when they choose which GP to register with.

We know that competition in general practice drives up quality (as it does in NHS hospitals). Giving patients OFSTED-style tables as proposed by Jeremy Hunt will, just like it has done for schools, create that competition. The transparency will act like a disinfectant, driving out poor practice and improving standards.

Effective competition requires clear, comparative information on which patients can make choices. Whilst it won’t be popular with the BMA, or those who want to maintain a cloak of opacity around the quality of General Practice, by making the bold move to extend the FFT across primary care the Secretary of State can – before the next election – create the “TripAdvisor of Health” for the NHS, and in a matter of months deliver unrivalled transparency and patient empowerment that for good reason will make the NHS the envy of the world.

Making ratings and reviews by patients standard across the NHS will create public demand for the Government to finally remove the archaic, protectionist system of restricting choice of GP to the few nearest practices. The Government has promised to remove this barrier to competition and quality, but once patients can see the variance, and understand – as doctors do – exactly what it means for the health of their families, there will be popular pressure for true choice. Enabling that choice will be both good politics and good for public health.

General Practice remains one of the last bastions of monopolistic protectionism with no transparency on quality. This does a disservice to the many, many excellent doctors and nurses delivering high quality outcomes and a superb patient experience. Extending the Friends and Family Test would ensure that such practices – and those they care for – thrived, whilst putting pressure on the poor performers to increase standards or see their patients transfer to those more highly-rated by the public.

Remember, your doctor chooses very carefully to get the best care for their family – shouldn’t you have that same choice?


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2 Comments leave one →
  1. March 9, 2013 12:49 am

    I am sceptical about much of what you write. It’s all a bit too black and white.

    I know quite a lot about the issue of GP practice boundaries and here you are on very shaky ground. I work in a practice which in one report was cited as the one with the highest satisfaction rating in Tower Hamlets http://bit.ly/UBdGfk . Yes, this was gratifying but we are in no position to accommodate patients wanting to join us: we are unable to register all the patients within our practice area who want to register with us so we are certainly not able to register those who live outside that area. In addition to this limitation, we also have over 20 years experience that tells us that looking after patients at a distance from the practice is full of problems and at times unsafe.

    The drive to de-regulate general practice by removing geographical boundaries will benefit some mobile relatively healthy patients (and Virgin Care) but it will actually create a systemic mess and harm many.

    If you are willing to have your views challenged, see http://www.gpboundaries.org

    (For the record, I think serious efforts should be made to improve the standard of general practice across the board so that everyone, wherever they live, has access to a ‘good enough’ GP practice, but that would require other strategies which nobody seems to be talking about.)

  2. rpdutt permalink
    March 9, 2013 8:44 am

    Do we really know that ‘competition drives up quality’? The evidence of its introduction into acute care suggests otherwise. As for rating GPs, Dr Shipman’s patients would have given him high marks

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