Health and Social Care Bill

My Lords, I support my noble friend Lord Kakkar’s amendment on the performance of general practice and primary care physicians. I am a fellow of the Royal College of General Practitioners, although after I have said what I am going to say, maybe I will not be any more. I hope that that not will happen, because I say this wishing to help my primary care colleagues. The noble Lord referred to the King’s Fund report, published in April 2011, which was an inquiry into the quality of general practice. The inquiry was conducted by an independent panel of experts, chaired by Sir Ian Kennedy, and represents the most extensive review of quality across general practice undertaken in recent years, bringing together a wide range of evidence for the first time. The inquiry concluded that, while the majority of care provided in general practice is good—I emphasise that—there are widespread variations in performance and gaps in the quality of care delivered by some general practices. There are variations in the quality of diagnosis, particularly for cancers. There are disparities in the rate of referrals; for example, there is an eightfold variation in the rate at which practices urgently refer patients with suspected symptoms of cancer to a specialist. There is variation in the quality of prescribing. It is estimated that the NHS could save at least £200 million a year through more efficient prescribing of drugs such as statins. The report also highlighted concerns that continuity of care is worsening, despite the evidence that this is what patients prefer and that they prefer to see the same general practitioner. Variations in the experience of patients and co-ordination of care highlighted by the report also included wide variations in admission rates for patients with conditions that could be treated outside the hospital. While we are promoting fewer patients going into the hospital, that is an important point. Only one in 10 patients with long-term conditions reports being told that they have a care plan, despite a policy commitment that all of them should have one. There are a number of challenges facing general practitioners: demographic change, higher patient expectations, new technology and medicine, and the changing environment in which they operate. The challenges are therefore accelerating the trend for practices to work as multi-professional teams, with GPs working closely with specialists and other professionals within and outside their practice, delivering a new deal for patients that involves them much more closely in decisions about their care. GPs are moving from being gatekeepers—usually keeping the gate closed—to navigators, co-ordinating care for people with complex needs and helping and guiding patients to other public services, and being held accountable for the quality of care provided, which is accelerating the shift away from small practices working in isolation towards a more federated network of practices working more closely with one another and other professionals. Practices are looking beyond their surgery door by focusing on prevention and taking a more active role in public health issues such as obesity and reaching out to deprived communities. CCGs will have a critical role to play in supporting quality improvement in general practice, monitoring the quality of individual practices and sharing their knowledge of this with the NHS Commissioning Board, which will hold the contracts of nearly 2,000 practice groups, and with the Care Quality Commission, which will be responsible for registering practices. It will also be important that the national contracts, the commissioning outcomes framework and the quality premium—no doubt we will discuss that in another group of amendments—are aligned to improve patient outcomes. The experience of the quality outcome framework, QOF, has been that it is too narrowly focused. Research has shown that it has not actually delivered in improving outcomes and is insufficiently ambitious in the performance benchmarks that it has used. With most practices scoring over 90 per cent against QOF measures, the National Quality Board concluded that it, "““is not sufficiently able to discriminate between performance””." In terms of measuring performance in primary care, and particularly in terms of measuring performance in relation to chronic diseases, the experience from the United States is quite interesting, and I shall quote it so that we can learn from it: "““All of the US groups in this study aimed to performance manage their doctors””—" this is in California— "““both specialists and primary care. For primary care physicians especially, where quality indicators were more prevalent, peer review of performance data on productivity and quality was relied upon as a valuable route to improved performance””." The document also says: "““It was common for data to be reported back to individual physicians, usually with names attached””—" a practice that is carried out in some specialities in the United Kingdom— "““The leadership of medical groups was clear that intra-peer competition was a powerful tool for improvement””." It states further, "““It is notable that the US medical group leaders were clear that the financial interests should never interfere with decisions about what was best for individual patients. In containing utilisation, they attempted to appeal primarily to doctors’ clinical professionalism””," and that CCGs and the NHS Commissioning Board will, "““have to make a convincing clinical case to their rank-and-file GPs for efficiency, based on evidence about service quality. Without this, GPs are unlikely to cooperate with a consortium’s wider goal of achieving cost-effective care””." My noble friend Lord Kakkar quoted the noble Earl being reported in the Health Service Journal. If I might tease him a bit more, he also said that CCGs and the NHS Commissioning Board would be better able to tackle performance than PCTs, and that the report that he approved of, "““makes clear we haven’t had sufficient levers in the system to expose substandard general practice in the past, and we do need to do that””." He might, then, be able to say what the thinking is towards achieving this.