Time to reform primary care?
Authors: Alan Maynard
Journal: Journal of the Royal Society of Medicine (2012)

The regular ‘re-disorganizations’ of NHS structures over the last 30 years have largely marginalized the reform of primary care provision by focusing on the development of commissioning and improving the performance of hospitals. The Thatcher reforms created the purchaser-provider split and instituted the notion of ‘trust’ hospitals. The Blair reforms saw changes in commissioners (health authorities to primary care trusts) and efforts to improve their performance e.g. ‘World Class Commissioning’, as well as greater autonomy for hospitals with foundation trusts and continuous efforts to improve safety and productivity in secondary care.

In contrast to this focus on commissioning and improved provision of hospital care, the purchasing and provision of primary care has been largely ignored. For instance, GP fund holding was introduced as an afterthought by the Thatcher government. During the Blair administration the quality outcomes framework (QOF) for general practitioners whilst radical and expensive, did not alter primary care fundamentally.

The failure of NHS reforms to focus thoroughly on the role of primary care as a provider means that practice variations and fundamental issues about the efficient delivery of primary care have been side-lined. This makes it imperative that in the current period of financial austerity, policy makers must seek to improve primary care productivity with a programme of radical reform inherent in the NHS reform documentation.1 How can this reform improve transparency, accountability and efficiency, and thereby contribute to the saving of £20bn required to maintain NHS services for an ageing population in the next 4 years?

In the new NHS structure primary care will be commissioned by the national commissioning board (NCB). Their apparent intention is to set national standards of process and outcome, and rigorously manage the performance of practices and practitioners.

The authors of the McKinsey report,2 using simplistic arguments, concluded that ‘5–10% of GPs are very weak performers and 15–25% are weak performers in the number of appointments offered per week’ They asserted that considerable savings could be made by ensuring that ‘weak and very weak GP performers achieve the standard performance’.

McKinsey's report offered neither robust evidence to support their assertions nor did they identify demonstrably efficient incentive mechanisms to remedy these performance deficits. However, their approach was accepted uncritically by naive policy makers who appeared to concur with the consultancy firm that general practice performance had a normal distribution, that lower deciles were ‘inadequate’ performers and average practice was desirable and ‘good’.

However, this material is indicative of the recognition of large clinical practice variations in primary care3 and an ambition in Whitehall to generate efficiency savings by standardizing processes and outcomes. This approach has evolved in principle over more than a decade, with a focus on process performance indicators,4 the introduction of the QOF in 2004, and the recent publication of the 60 item NHS Outcomes Framework.5 Some of these variations may be indicative of good, bad or uncertain clinical practice. However, until now they have largely been ignored, and when altered will produce significant efficiency gains.