From the consulting room: Who’s checking the GP’s pulse?

This article first appeared on Microsoft’s NHS Resource Centre on 04 May 2011 (site now defunct; ).

Neil Paul asks if GPs emerging into a brave new world of commissioning could do with some IT performance management.

There is a lot of talk at the moment of Kaiser Permanente (the US-managed care organisation that looks a bit like the NHS and is often held up as having good ideas for reforming it), about A&E and front doors to hospitals, and about variation in primary care.

The unifying factor seems to be an understanding that the NHS urgent care bill is huge and ripe for having costs squeezed out. For ages, we have heard mutterings about giving the patient a choice of provider for operations and procedures, but elective care is small fry in terms of cost.

These topics also reflect the increasing focus on primary care’s role in avoiding hospital admissions. Perhaps the reason for GP Commissioning is to have poachers turn into game keepers? If so, we’re going to need better IT systems to help us patrol our new territory.

Treating more efficiently

The long-term conditions with which patients suffer are of course still important, but the current focus is on primary care optimising the treatment of those patients to obviate their needing a hospital admission - and equally on finding the ones we don’t know about.

The Quality and Outcomes Framework tried to drive up the quality of outcomes on existing disease registers. It has largely failed in my opinion, not because of gaming or cheating as some people suspect, but because it has become too process-oriented.

It measures the wrong things. It doesn’t do anything to understand the variations in actual disease register size compared to predicted size. And it doesn’t do anything to compare the costs of two practices achieving the same score, with the aim of pushing for efficiency savings.

In fact, at the moment, you often score more by prescribing more often rather than more cost efficiently. Practices also vary in their use of NHS resources for delivering the same care. Tools need to be developed to address this.

Spotting problems – before they get to A&E

Kaiser promotes joint working, a shared health record, and teams working around the primary care physician to optimise care, prevent admissions, support early discharges and avoid readmissions.

Compare that with my current situation. The first I find out about an admission will be days after discharge - if I’m lucky - and I will be barely able to work out what it was for or what was done.

Although electronic systems exist to transmit this discharge data, there is no intelligence from the system – recording frequent fliers, spotting trends or activity levels per practice. Better systems are needed.

In the meantime, it feels like the whole country is arguing about how things are charged, what counts as an admission and what constitutes a ward attendance. Yet this all gets in the way of actually trying to get fewer people to go to hospital.

We know there are many factors that lead to an admission: proximity, health knowledge, deprivation, family support, past experience, even the weather. What surprises me is that as a system we have no real knowledge of admissions activity and no way of predicting it.

A&E doesn’t seem to vary the number of staff on duty, depending on how busy they think it will be. They just run a shift system, despite historical data showing clear patterns of demand.

I’m convinced that general practice gets busy about two days before the hospital starts running out of beds. So why isn’t the A&E patient administration system and the GP appointments systems all feeding an overview?

Throw in weather and a few other variables and I’m sure you could build an early warning system that would allow you to adjust resource at different points of the ecosystem.

Looking at our own access

Of course, some might be concerned about reporting primary care activity – as this might show the variations in it.

The variation in primary care report by the King’s Fund and work done in London with the help of McKinsey has shown that there are huge differences between practices.

Some do two two-hour surgeries per day; and shut for four hours every lunchtime. Some open 8am to 6.30pm and pretty much have appointments running all day. Is GP access the elephant in the room?

Have we properly matched out-of-hours attendance and A&E attendance to level of access at the patients’ GP surgeries?

The figure of 72 GP appointments per 1,000 patients per week is held up as being a marker of good access, yet I don’t know of any easy way of working this out per practice, either from within a practice or a consortium. Why isn’t this reported weekly, at least to the practice manager?

Keeping a check on our own performance

Operationally, there are a lot of other things that GP practices don’t readily know. We have moved towards a salaried service - and some might argue a shorter training period. So it could be argued that the owners of the business need to know more about the performance of their employed clinicians.

Yet prescribing systems don’t readily identify who has prescribed what. Referral management systems don’t easily produce data on who has referred what to whom and what percentage of the cases they have seen they are referring.

So, in my view, the computer systems of the future need to measure and feedback. They need to read code quality, clinician activity and follow up rates per condition per clinician; all of which might be used for performance management.

We are all familiar with the Partner who does nothing but measure blood pressures. What about measuring intervention rates?

As a doctor, if I’m not adding new diagnoses, changing treatments or referring the patient, what am I doing? Just having a chat? For some conditions, this might be good. But what percentage of my consultations should have an intervention?

I think there is plenty of scope for IT to help deliver the GP commissioning agenda. There is a lot I haven’t covered here - come and see my talk at the Primary Health Info conference (May 9 and 10) for some of my other ideas, and for more detail on what is sketched out above.

About the author

Dr Neil Paul is a full time partner at Sandbach GPs, a large (21,000 patient) practice in semi-rural Cheshire. Until recently, he was on the PEC of Central and East Cheshire Primary Care Trust, with responsibility for Urgent Care and IT.

He is now on a journey into the unknown. He is on the board of his local consortium, one of many on a pilot leadership programme, and looking at provider opportunities. He recently set up a successful primary care clinical trials unit and is involved in several exciting IT projects.

Further information:

Dr Neil Paul is a regular columnist on the EHI Primary Care website where this piece originally appeared.

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