General practice is strong but must evolve to survive, says King's Fund expert

King's Fund senior fellow Nick Goodwin speaks exclusively to GPonline.com about the results of the inquiry into the quality of general practice.

Back in April 2009, when the King's Fund launched its inquiry into general practice, GPs had their reservations as to what it was trying to achieve.

Some saw it as an attack on the profession by a 'bunch of academics looking for errors and poor performance'. But now, as the report is published two years later, will these fears have been realised or quashed?

King's Fund senior fellow Nick Goodwin, who led the inquiry, says from the beginning he was concerned it would be seen as a 'stick to beat the profession with'. But he insists that it is 'not like that at all'.

He says the inquiry shows that the quality of clinical care provided to patients is 'generally good'. It also recognises GPs have improved quality of care in recent decades in clinical areas including long-term conditions and diabetes, he says.

But Mr Goodwin also says variations exist in 'pretty much every dimension' of general practice, some of them so large that there are questions to be asked. He adds that general practice will have to 'change significantly' to meet future demographic and political changes, and patient demands.

Creation of federations
For one, he says general practice will need to operate 'at scale'

and says there is an 'urgent need' to accelerate work to create federations.

Within practices there is a need to develop skill mix, he says, with nurses taking on a greater role in caring for people with long-term conditions.

Specialists should work alongside GPs to provide support in diagnosing complex cases, he says. But he adds that this does not mean moving into polyclinics. 'What's so crazy about the current system is that a GP cannot phone a sub-specialist in the hospital for a second opinion,' he says. 'How stupid is that?'

He says general practice will need to be 'more proactive' in preventing ill-health, and has to work closer with councils to improve health locally and reduce health inequalities.

But can this vision be achieved against a backdrop of reorganisation in the NHS?

Mr Goodwin thinks the reforms are a mixed bag. GP commissioning could improve quality in general practice, because it will promote peer review of GPs' work, he argues.

This could be a strong lever to improve quality as it 'feeds off the profession's personal competitiveness', he says.

He also says the 'quality premium' proposed by the government is a 'good idea in principle', as it provides a 'discipline among general practice' to meet the requirements of the quality agenda.

But he warns that the government 'must avoid like the plague any notion that it will be linked to the ability to make savings on budgets'.

Quality improvements
Mr Goodwin also warns the reforms could shift focus away from improving quality and says the Health Bill does not properly legislate for closer working between local authorities and GPs. The inquiry could reassure health secretary Andrew Lansley that GP commissioning is the right approach, he says.

But it also questions why incentives aren't aligned to ensure GPs work closely with councils and asks why the government is focusing on competition and choice rather than integrated care. The inquiry sends a 'clear message' to government that more needs to be done to support quality improvement in general practice, he says.

Mr Goodwin is clear that excellence must be rewarded, both financially and non-financially, and poor quality practices supported to improve. He says GPs who enhance quality could be given opportunities to specialise or take time off to address their work/life balance.

'It's not just about cracking the whip and asking people to work harder,' he says. 'It's about creating an environment that's pleasant to work in and is productive as result.'

So while it highlights concerns, the inquiry says rewarding excellence is key to addressing this and looks at how GPs' lot could be improved.

Despite concerns GPs might have had about the report, few are likely to argue with this approach.

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