Quality in general practice
Improving the quality of general practice care for patients has always been at the heart of the College’s mission. This position statement builds on previous definitions of quality from within general practice and across health systems. It also builds on the content of the General Medical Council’s Good Medical Practice. In doing so it reflects both the enduring and changing features of general practice in the NHS across the Devolved nations. The position statement describes how the College wants to move from a standards-based assurance approach to a model that emphasises the importance of continuous improvement.
We have developed the position statement for people who provide general practice care for patients, and for those making judgements about the quality of general practice care.
There is good evidence that health systems with a strong focus on general practice deliver better outcomes at lower cost than those that are more specialist-oriented.
These benefits can be achieved by:
- providing accessible care to all communities, including those with the greatest need
- a whole-person and relational perspective rather than a purely disease-based approach
- managing uncertainty and reducing risks of over-medicalisation
- providing comprehensive services especially to those with multi-morbidity
- focusing on prevention and promoting self-care.
This position statement aims to enable each of these components of high quality general practice.
All GPs strive to provide the best possible care for patients, families and communities. They take responsibility for the care they provide to patients, and for their clinical and professional non-clinical practice. In practice this means that they:
Focus on improving the experience of care for patients, carers and families:
- Acting in ways that show kindness, empathy, honesty and integrity, listening and sharing decisions in line with patient preferences.
- Being receptive and responsive to feedback on the care they provide to patients and being committed and actively participating in the process of continuous quality improvement.
- Providing person-centred and coordinated care, understanding the interaction between physical, psychological, and social issues and working closely with key partners such as the extended Primary Care Team, voluntary, community and social care sectors.
- Delivering continuity of care for patients, especially those with complex needs, by ensuring that whenever appropriate and possible, patients feel that their clinicians know about and understand them and the context that they live in.
- Supporting patients to take control, understand their choices, set and achieve their goals by assisting them to gain the knowledge, skills and confidence to make the right decisions for them and to optimise their health and wellbeing.
- Encouraging and empowering patients and their carers to become equal partners in the co-creation of local services that address their needs and the needs of their local community.
- Ensuring the best possible access to advice and services that meets patients’ needs within the resources available and being advocates for those patients who do not receive timely clinical management.
Demonstrate clinical competence by:
- Providing clinical care and preventative advice that is informed by the available scientific evidence and local care pathways, is tailored to patients’ preferences and priorities and supports people to improve their health and wellbeing.
- Dealing effectively with uncertainty and managing risk with care and clinical acumen, in a way that reduces the risks of over-medicalisation.
- Having the knowledge and skills of care and support planning and utilising such an approach to provide person-centred and coordinated care.
- Ensuring they are aware of local and national guidelines and services and using these guidelines in a way that recognises the needs and preferences of individual patients.
- Working as part of multi-professional teams and practice networks, making appropriate referrals that navigate patients effectively through the complexity of the NHS and other services.
- Being committed to a journey of continuous improvement, utilising Quality Improvement (QI) tools and the available evidence and reviewing service delivery to ensure this is sustainable, cost-effective and meets the changing needs of patients.
- Adapting to changing models of healthcare that require new balances of professional skill-mix, and ‘at scale’ delivery of services to improve effectiveness and efficiency for patients.
- Minimising any harm that might result from their actions, balancing the risks and benefits of medical interventions and sharing these decisions with patients.
Assume responsibility for their own, and their peers’ professional standards by:
- Leading and participating in systematic and evidence-informed approaches to improving patient care and health services.
- Being committed to their own development, and that of their peers and the wider profession, through teaching, research, and appraisal.
- Being aware of their own boundaries, limitations and health and adapting working patterns accordingly.
Assume responsibility for the wider environment by:
- Understanding the needs of their communities and populations and working closely with those involved in planning the delivery and evaluation of local health and social care services and the voluntary sector to ensure coordinated and cost-effective care delivery.
- Addressing the needs of more vulnerable members of the community in order to reduce inequalities.
- Contributing, as both individuals and local community leaders, to the achievement of best possible value for money, the avoidance of waste and the sustainable use of resources.
- Using systematic and evidence-informed approaches and tools to improve patient care.
- Engaging in wider debates about the future of general practice and being willing to challenge practices and policies that may damage patient care.
Assessing the extent to which these elements of high-quality care are delivered is an important pre-requisite for improving them. Some of the elements can be measured with a reasonable level of scientific rigour and in some cases, data are available that allows judgements to be made about unwarranted variation in quality. For others, current measures may not be robust. For an important part of what GPs do, such as managing uncertainty, there may be no reliable or valid measures, but these nevertheless need to be valued.
The challenge of delivering high quality care in the real world
It is not possible in the real world to achieve excellence on all of these dimensions all of the time. There are a number of reasons for this. First, high quality care is dependent upon adequate resources, health professionals who are mentally and physically healthy, and a working environment that is conducive to supporting effective professional practice. These elements are often either missing or outside the control of individual clinicians. People need to be supported and to feel valued in order to do their work well. Time spent developing QI must be recognised as part of core service delivery. The quality of the experience of the caregiver (in this case the general practitioner) is also important.
Second, there may be inherent tensions between the different dimensions. For example between implementing scientific evidence and respecting patient preferences, or between providing good access and the costs of doing so. Third, as the Quality and Outcomes Framework and regulatory activities have demonstrated, pressures to deliver preferentially on some dimensions of quality over others can distort clinical care. This may lead to unintended consequences.
This Position Statement clarifies the current RCGP position on quality in general practice. It will need regular review, in response to changes to NHS structures and the role of the GPs in healthcare. It can be used to benchmark quality in a number of contexts in general practice, both within practice settings as well as ‘at scale’, in commissioning and planning new healthcare services for patients.