The Maynard Doctrine: Improving primary care: three challenges

Professor Alan Maynard’s presentation for the NHS Alliance conference today explores the three main challenges confronting primary care in a ‘Liberated’ NHS


Some assert that primary care in the NHS is the “best in the world”. The evidence for this assertion is poor, with limited evidence of good practice accompanied by evidence of poor access and uneven delivery of services.

It is remarkable that primary care remains “data-lite”, with taxpayers paying for variable service quality for over 60 years.

Improving primary care
Three primary issues for reform are:
i) Data collection and analysis
ii) Incentives
iii) Skill mix

i) Data collection and analysis
For decades, I have pointed out that we lack basic activity data about primary care. Hospital episode statistics (HES) is a comprehensive data source about hospital activity; but no equivalent exists for primary care.

HES give information about GP referrals. The Prescription Prescribing Authority provides data about GP prescribing activity. The GP-Quality and Outcomes Framework (QOF) provides information about QOF activity.

However there is no routine collection of consultation rate activity for primary care practices.

Significant and urgent investment in data collection and analysis in primary care is essential if there is to be greater transparency and accountability. Only with such an investment can baseline performance standards be identified and used as a means of measuring performance and improvement in service delivery

ii) Incentives
Financial and non-financial incentives, such as those of trust and reputation, have powerful effects on the behaviour of providers. These effects can be beneficial or perverse e.g. the QOF incentives had a rapid and significant effect on the delivery of process activity, but there is evidence that the health gain produced by achieving these process targets was modest in some cases.

The QOF needs urgent revision, and one element of this should be the inclusion of patient-reported outcome measures (PROMs).

Since April 2009, all hospitals are required to collect ‘before and after’ quality of life data for all NHS patient receiving hernia repairs, hip and knee replacements and varicose vein operations. The analysis of these data is now showing considerable variation in the performance of hospitals in terms of restoring physical and psychological functioning of patients.

In time, it will show variations in the performance of individual clinicians.

GPs should be incentivised to collect PROMs for all patients consulting them. Whilst waiting to visit the doctor, the patient would complete a quality of life questionnaire (e.g. EQ5D: www.euroqol.org) and sequentially this would provide the GP with a time series of patient assessments of their health status.

This could be useful for determining diagnosis and treatment, and would also demonstrate how successful GPs were being in maintaining their patients’ quality of life.

Complemented by PROMs measurement for hospital procedures, such data would give GP consortia basic data to discriminate amongst competing providers.

Without the use of PROMs in primary care, the role of commissioners will be difficult, leaving them unable to ensure value-for-money for taxpayers and patients.

PROMs data collection could be incentivised by mandate and by payment through the QOF.


iii) Skill mix: using fewer GPs in primary care
The evidence (e.g. systematic reviews in the Cochane Collaboration data base) suggests that well-trained nurses can carry out most of the tasks of a GP. There are now over 30,000 nurse practitioners with full prescribing rights.

The GP QOF was largely implemented by nurses, although GP practices were paid for this work.

The British Medical Association continues to advocate smaller list sizes. However, the evidence here indicates that with triage and well-trained nursing input, GP list sizes could be doubled or trebled.

GPs are expensive. In times of austerity, skill mix changes (such as nurses replacing GPs) may be financially attractive and equally effective in terms of delivering patient care and ensuring patient access and satisfaction.

If NHS organisations are slow to exploit such opportunities, through the service tendering process, it is likely that private firms will exploit these commercial and medical opportunities.

Summary
Primary care is a suitable case for radical change. Its provision needs to be ‘industrialised’, with ‘corner shop’ enterprises fading away to be replaced by ‘supermarket’ consortia that exploit economies of scale and efficient skill mix options.

Without rapid reform, and given the funding constraints, change is needed urgently if the quality, quantity and distribution of access to care are to be improved.

Sadly this has been obvious for decades but the sector has largely maintained its “cottage industry” status - as exemplified by its Lloyd George system of patient records!

Surely we should celebrate the centenary of the 1911 National Insurance Act with some real reforms rather than a further exercise of “shifting the deckchairs on the NHS Titanic”?