The History of the RCGP
Quality: Our Outstanding Problem
Donald Irvine (1983)
Despite many major improvements, unacceptable differences in the
quality of general practice still persist today. Such differences
are often more obvious to our patients, practice staff, nurses and
local specialists than to ourselves. I suggest that in general
practice there is now sufficient self-confidence to require all of
us to look afresh and more rigorously at what we do for our
patients because there is always scope for improvement. I know my
own weaknesses (for example. I regularly start surgery late which
irritates patients; I am not as good as I should be in the
diagnosis and treatment of skin conditions), and therefore I know
where I have to try harder.
Although in our inner cities unsatisfactory working conditions
are still common, generally we have to face the fact that where
there is poor care it is often the result of a practitioner's
incompetence, or unwillingness, to give the time and attention to
provide a basic service. Our College, founded to tackle this
question of quality, has had some notable successes in the
past when numbers were small and members were regarded as untypical
of general practitioners as a whole. Times have changed. The
College is established: it is growing rapidly; it is increasingly
representative of general practitioners under 40; and it claims
considerable responsibilities. People, especially outside the
medical profession, are looking to the College in the expectation
that individual members will be rigorous in setting and maintaining
their standards of clinical practice.
So the days of freewheeling, of having influence without
responsibility, are virtually over. As a College we are required
now to address the problem of quality with a new sense of urgency,
determination and purpose.
Independent contractors: the test ahead
For the immediate future the independent contractor
arrangement will continue. Most practitioners like it, earnings in
general practice are comfortable, morale is generally good, the
quality of new recruits is high, lists are falling, and patients
are either content with, or relatively uncritical of, general
practitioner services. The government and the rest of the
profession are still of a mind to see whether we have the will and
ability to furnish a future service of high quality within the
present contractor framework. Such generally favourable conditions
can themselves induce complacency and poor motivation. Therefore
our foremost challenge is to show that we independent contractors
are capable of establishing an effective system of self-regulation
to provide primary and continuing medical care of a standard which
will be regarded as not merely acceptable but highly desirable by
the community at large.
The possible consequences of failing to grasp this nettle do
not seem to be understood by many practitioners. They are indeed
profound and must be spelt out and broadcast widely in our
branch of the profession. If we fail to tackle the quality issue
thoroughly and decisively now, forces outside and around general
practice could move quite quickly, singly or in concert, to
undermine our foundations even though we can demonstrate large
pockets of success through examples of good practice. For instance
in our own profession specialists are beginning to look for work
outside as well as inside hospitals. Paediatricians, psychiatrists,
and geriatricians are the best illustrations but physicians and
obstetricians could join them. The pressure on hospital specialists
to expand beyond their conventional boundaries in the UK, and thus
operate like their counterparts elsewhere in Western Europe and
North America, could well increase as more doctors chase fewer
hospital jobs and as more part-time doctors seek inclusion in a
hospital specialty rather than in general practice to do clinics
and other sessional community work. On a somewhat different tack,
the nurse practitioner as an alternative provider of primary health
care hovers in the background—such practitioners are seen by their
advocates as a substitute for general medical practitioners
especially in conurbations.
It is against this potentially unstable background that we can
expect governments to act if we general practitioners are judged
overall to be failing our patients. Thus, I understand, a future
Labour government would try to solve the problem of accountability
in general practice by introducing a full salaried service, that is
a medical hierarchy in which career appointments are statutorily
defined and graded. There are several working models around the
world. A future Conservative government could be expected to seek
greater accountability through a more rigorous definition and
arrangement of 'the contract'; such an initiative could be helpful.
If this policy failed, the government could well move on to offer
patients more choice by loosening the monopolistic bonds of the
referral system, so that hospital specialists could compete with
general practitioners as providers of primary medical care in our
big towns and cities. All major political parties have indicated
that they intend to try and increase the effectiveness and to
reduce the cost of prescribing in general practice by one means or
another because, they hold, we have failed to devise generally
acceptable measures ourselves.
I have sketched this uncomfortable scenario of alternative
options at some length because they are real and therefore must be
taken seriously and faced squarely, especially by any practitioner
who is under the age of 40 and who still has most of his career in
general practice ahead. It is not my business to argue the case for
the alternatives: on the contrary, I believe in the potential
strength of general practice if we take our responsibilities
seriously. Therefore I am committed to make it work.
I suggest that people in a society which can afford primary
medical (rather than primary nursing) care will choose also to
retain general practitioners as their first choice of personal
doctor because of the well known assets which good general practice
has. Good general practice is unchallengeable; it is poor general
practice which is replaceable.
In our pursuit of quality we can expect help from an
increasingly articulate and discerning public which is being
encouraged to question the quality of our service by special
interest groups and the media. Such questioning should be welcomed
for it provides a much needed customer stimulus even though it may
expose our weaknesses with a degree of precision and frankness to
which we are not accustomed.
The pursuit of quality
Strategic aims
At the heart of a new policy is the need for each of us to know and
understand the nature of our clinical work at any point in time, to
be able to explain to patients what services are currently
available, and to be able to project forwards so that new policy
objectives can be defined and the achievement of these
monitored.
I suggest that within general practice as a whole each of us
should be able to achieve the following broad aims within the next
10 years:
1. To be able to say, at any moment of time, what the content
of our work is and therefore what services each of us
provides.
2. To incorporate standard setting and performance review as
an integral and effective part of our professional lives.
To achieve these aims a package of specific policies will have
to be devised. The most important are professional but some will
need new resources, some will require a more rigorous
administration of family practitioner services, some could involve
alterations to Terms and Conditions of Service, and some will
reshape our relationships with patients and other professional
colleagues. This list should not be difficult to make. The
important point is that the development and prosecution of a
general policy must be based on combined operations, over a period
of time, involving the College, the General Medical Services
Committee, and the local medical committees, government and health
authorities, and of course patients.
Experience shows that the College succeeds best in promoting
change by enlisting the help and support of its committed members.
It follows that the College can begin to make its contribution to
improve standards of care in general practice by leading from
within, aiming to establish standard setting and performance review
within our own members' practices as a working model.
The following are objectives which might further discussion on
priorities and help give a sense of direction. I suggest that in
the next five years we should be able:
1. To describe our work and therefore the services we provide
for our patients.
2. To introduce standard setting and performance review as a
normal part of a College member's way of life.
3. To establish the MRCGP/FRCGP in the public mind as our
hallmark of continuing quality, our own indicative specialist
register.
4. To set high standards for vocational training and to
monitor these so that they are observed.
5. To provide comprehensive services for associates and young
members.
6. To secure sound practice management in the practices of
College members
7. To establish effective working relationships with nurses
and health visitors in College members' practices.
8. To create working links with local medical committees,
family practitioner committees and district health authorities so
the College members can help tailor their services to the needs of
their communities.
Can we do it?
The fundamental change in attitudes, habits and practice which
the proposed policy implies will not happen by accident, by a
laissez-faire approach. On the contrary I believe that a concerted
effort must be made using every part of the College. We
demonstrated similar single-mindedness when vocational training
looked more of a mirage than an achievable target and we succeeded
despite many obstructions on the way.
What are our assets?
I suggest that there are three main elements:
1. We ourselves
We are our most valuable asset. If each of us in the College
is prepared to invest the time, money and effort necessary to
achieve the aims in our own practices the job would be nearly done.
Personal commitment and motivation are fundamental.
2. The faculties
Currently under-developed, the faculties should become the
main vehicle through which we College members can work out and
monitor our standards of care, organise at least part of our
continuing education, and provide information from our own
practices which should enhance local general practice services.
This implies direct support when needed for our members and their
practices and help locally for the local medical committee and
district health authority in securing the resources needed for
effective practice.
In England our faculties are large and mostly coterminus with
health service regions. They have to be made more accessible and
more manageable. One alternative is to reduce faculty size (as in
Scotland), perhaps following family practitioner committee or
district health authority boundaries according to local preference.
The other is to create local subdivisions within existing faculties
so that the College has an identifiable local presence. In either
case it will be important to retain a regional tier in England (or
the National Councils in Scotland, Wales and Ireland) because it is
important to maintain links with the regional health authority and
local university. The smaller faculties or subdivisions should be
responsible for making our local College work. New money will be
required. Several sources are open to us but an important part must
be a return of a greater proportion of the membership subscription
as our membership and income increase.
3. The central College
The central College has functions which only a national body
can carry out, so the headquarters' organization must continue to
discharge these as efficiently as possible. However, the central
College should have an important role in faculty development. For
example, the administration of the College needs to set new
standards of service and should be responsible for managing the
College's information network and library. The Divisions should
forge new links with their counterparts in the faculties, so
encouraging more young members to take an active part in the
College's affairs.
Overall the central College, like the faculties, should
concentrate on the general function of making the individual
members' pursuit of quality in their own practices as easy,
effective and enjoyable as possible.
In conclusion
We have talked about improving the quality of care in general
practice for long enough. We should now adopt a policy which can
turn hopes into reality in the next five years within the College
and in 10 years within general practice as a whole.
DONALD IRVINE May 1983 Chairman of Council
Addendum This document was first published in
the Journal of the Royal College of General Practitioners
(1983) 33, 521-3.