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How do you measure quality in general practice?

It all began when I was asked to comment on a particular doctor’s performance as part of a role I have on the PCT.

It all began when I was asked to comment on a particular doctor's performance as part of a role I have on the PCT.

You might think that I would have a good idea of who the good doctors and who the bad doctors are in my locality, but actually we work as a large number of individual entities in general practice, so I really have no idea what the people are like at the next practice: they might be great, they might be terrible. I don't know.

The Clinical Governance people wanted me to comment on whether I thought there was a systemic problem within this doctor's practice, following a complaint about a late diagnosis and a death. I do have some expertise here as I have done medical reports for the last few years for a medical indemnity organisation as an expert witness, so I have been this way before.

All I knew about this person was hearsay. I had no robust or reliable information about the doctor. The practice was single-handed, and the GP did not have MRCGP. Do these factors matter? In general people with MRCGP get sued less often, but one of the best doctors I worked with did not have MRCGP. There are some excellent single-handed doctors in my patch, and some ropey group practices, so this information was pretty unreliable.

So I asked for the file of previous complaints about the doctor, and there was little there. This got me thinking: if I was a patient, what would I do? NHS Choices has no feedback. iWantGreatCare (lousy name, lousy site) did not even list the doctor. So how about the Quality and Outcomes Framework (QOF)?

The QOF is a management tool to measure performance. In the spirit of George Orwell's Animal Farm (where the animals were categorised as ‘four legs good, two legs bad') you would think that this is an easy system by which you can work out how good or how bad the clinical care in the practice was.

I looked the practice up, and the doctor had scored a top score: full house, three treble 20s, a perfect 10. I have to say that I was really surprised, as my own practice was about 20 points short of a perfect score. The other evidence I accrued suggested problems within the practice: a regular throughput of staff and patients, a consistent and regular number of complaints of varying severity.

How could all the remaining evidence be so wrong if the QOF was 100%? My own personal view is that there is a lot of gaming going on in QOF. There will be a lot of exception reporting, and manipulation of disease registers. Depression can be recategorised as ‘low mood', and there will be a load of BPs put on the system in the last 3 weeks of March (I was asked about this one) and BPs that are amazingly 148/78. A lot.

We have just had the spectacle of a hospital that is damned by one set of regulators (CQC) and praised by another one (Monitor). This has happened in social services, where Haringey was described as ‘good' when the Baby P case was going on.

Being a doctor is a difficult thing to do, and it is hard to measure. The measuring tools are crude and often inconclusive. I found this with the case of the person I was asked to investigate, and so it is likely to be in other environments.

So I would treat with scepticism many of the crude measures proposed.

Simply too inaccurate.

Jobbing Doctor

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