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At the heart of general practice since 1960

The data doc

Fresh from the authorisation process, our diarist turns his attention to performance management of GPs – and the thorny dilemma of acceptable versus unacceptable variation

The story so far

Cumbria is go! Well, almost. Next month, Dr Peter Weaving should find out if he is vice-chair of one of the first CCGs in the country to be authorised. It follows weeks of paperwork, meetings and board visits but the reality is very close. Once authorised, Cumbria CCG will be in charge of a £650m health budget (gulp). Now it just needs to address some more fundamental issues – such as what is acceptable variation…

‘Peter, I ask you again, what is acceptable variation?’ pressed Colin, the immutable Ulsterman. ‘That is the fundamental question we have to address.’

He was referring to the clinical behaviour of GPs and it’s a recurrent, if difficult-to-define, issue. One of the functions of CCGs is to improve the quality of primary care.

This is an interesting concept in its own right – these are our member practices, over which we have no direct contractual relationship. Yet our success or failure as commissioning organisations is completely dependent on what they do or, from Colin’s point of view, don’t do. It’s the docs who spend the lion’s share of the NHS budget through their referring, prescribing and admitting activities.

One of my concerns is the bottom-line finances and the wise use of limited resources but Colin – as our cancer lead, upskilled and indeed, part sponsored by Macmillan, the cancer support charity – can turn a Nelsonian eye to the finances. He believes that we need to spend more. More X-rays, more scans and more referrals, to improve our cancer outcomes.

He is vociferously passionate about his mission. Nationally we have poorer outcomes for cancer than comparable countries and massive inequalities, with deprivation being a key driver to the extent that, even with the same grade and stage of cancer, the affluent patient is more likely to survive. Locally we have standardised mortality ratios in our poorer wards that are 100% higher than the national average.

Colin is on a quest to fix this. Working with the local authority, he is recruiting cancer champions in the worst-affected city wards. More important, he is coming to your surgery to look you in the eye and ask his question. What is acceptable variation?

He comes armed with the truth – the nationally and locally available data about your own practice. He will politely and firmly take you through the number of your patients who were not diagnosed by you or a commonly available screening test, but were only diagnosed when they presented as an emergency in A&E with some complication of their, usually, more advanced cancer.

He will show you your use of guidelines, such as the two-week rule criteria for urgent referral of suspected cancer; invite you to explain why you refer such patients far less commonly than your peers. He will enquire why only two thirds of eligible patients of yours come for
a smear test at your surgery, why only half take up bowel screening opportunities or attend if invited for a mammogram.

Colin will listen attentively while you, perhaps reasonably, rubbish the data but then press you to tell him how to improve the recording and reporting of such data so he can improve its central collection and processing up the line. He will perhaps ask you to look personally into the medical records of some of your patients with less good experiences and outcomes to verify, or otherwise, the facts. This is important so that when he visits next time, you will have more confidence in the data and be able to answer his question about what is acceptable variation.

Because he will be back.

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