Quality in primary care is complex, and due to the nature of multi-disciplinary care and the many conditions treated, it is by its nature multi-dimensional.34 Health outcomes, both in terms of positive health and absence of disease, are the ultimate measures of the quality of primary care, but also require appropriate structures and processes for their achievement.34 The dimensions of quality have been the subject of significant debate. Recent work in the United Kingdom has attempted to articulate the core dimensions of quality as clinical effectiveness; safety, and patient experience.34,64
Patient experience has not always been a key dimension of clinical quality, with the focus on effectiveness and safety. In general practice and in primary care, patient-centred care is a core value.65 Despite this, there is evidence of less than optimal levels of patient experience and patient engagement.34 It could therefore be assumed that assessment of patient experience is an important element of any quality approaches in primary care.
Traditionally, many of the health system initiatives to improve quality have been implemented in the acute health care sector.66 While a number of approaches to ensuring high quality health care in primary care have been reported, evidence for their impact is limited in part because of recency of focus in this setting.66 Where evidence does exist, it suggests that larger practices have higher levels of performance than single practices.4 Clinical audits and significant event audits are commonly reported within general practices, but often in the absence of a systematic approach to quality.67
Critical to quality improvement approaches in primary care, and important to accountability for funds provided by government, are a set of robust indicators.59 Despite the evolution of primary care in developed nations, there is limited consensus on the indicators which are used to measure the impact and performance of primary health care systems.66 Where evidence of a focus on quality improvements does exist, it is in areas where measurement is easiest, such as in prescribing practices.49
Cross professional clinical leadership is considered a prerequisite for ensuring quality across the whole primary care team.66,67 Access by all members of the primary care team to robust data on agreed indicators is needed to determine areas for quality.66,68 The focus on team-work as part of the overall approach to quality is strongly recommended, given the inherently team-based nature of general practice.68 Approaches should engage and empower staff in measuring and improving quality, accountability for improvement and continual, rather than periodic approaches to quality.68
While most health care is provided in primary care there is evidence that the quality is variable suggesting considerable scope for improvement.34 For example, an Australian study reported that only about 50% of patients with diabetes received care reflecting evidence-based guidelines.69 Evidence also suggests that two errors occur for every 1000 Medicare items in general practice.70
Many of the approaches to improving quality in primary care appear to be project-based, such as collaboratives and development of disease-specific protocols and guidelines. However, there is a view that these project approaches are not embedded into primary care as part of its inherent culture.34 This is, in part due to lack of robust data and measurement tools, which can contribute to understanding variations in quality outcomes.34 In Australia it is further attributed to lack of agreement on the outcomes for primary care and mechanisms for their collection.
There is evidence that attempts at achieving quality outcomes are occurring in GP Super Clinics but are focused on projects with little attention, understandably at this stage of their maturation, to embedding the systems in to everyday practice. There were examples of participation in collaboratives and adoption or some adaptation of evidence-based guidelines. The process of collaboratives has the potential, on a project basis, to support mechanisms for quality improvement. However, in the absence of their application in a more strategic framework their ongoing use and effectiveness are more limited.
In meeting the future health needs of the population, primary health care needs a strong research and knowledge base and research culture.71 To date, there has been an over-reliance on research undertaken in hospital or specialty settings which do not reflect the models of care, patient populations or contexts of primary care.71 Where guidelines have been used they were mostly related to adaptation of evidence-based guidelines for particular conditions such as those of the RACGP. These are not necessarily multi-disciplinary in nature, and do not necessarily reflect evidence from multi-disciplinary settings. Given the close linkages with universities at some GP Super Clinics, there are opportunities for research on interventions in these unique settings, with the ability to shape the nature and quality of primary health care. The uniqueness of the multi-disciplinary nature suggests the potential for linkages in research, with a focus on intervention effectiveness, across all GP Super Clinics. To be of maximum benefit, such research should involve collaboration between researchers and clinicians from GP Super Clinics. Rather than just being points for data collection, the GP Super Clinics should have an active and strong role in determining research questions, measures and interventions.
4Imison C, Naylor C, Maybin J. Under One Roof:Will polyclinics deliver integrated care? London: King's Fund 2008.
34Improving the Quality of Care in General Practice: Report of an independent inquiry commissioned by The King’s Fund. London: The King's Fund;2011.
49Phillips C, Pearce C, Hall S, et al. Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence. Medical Journal of Australia. 2010;193(10).
59Pan-Canadian Primary Health Care Indicators: Pan-Canadian Primary Health Care Indicator Development Project: Report 1 - Volume 1. Ottawa: Canadian Institute for Health Information;2006.
64Raleigh V, Foot C. Getting the Measure of Quality London: The King’s Fund 2010.
65Hudon C, Fortin M, Haggerty JL, Lambert M, Poitras M-E. Measuring Patients' Perceptions of Patient-Centered Care: A Systematic Review of Tools for Family Medicine. Ann Fam Med. March 1, 2011;9(2):155-164.
66Goodwin N, Dixon A, Poole T, Raleigh V. Improving the Quality of Care in General Practice: Report of an independent inquiry commissioned by The King’s Fund London: King's Fund 2011.
67Siriwardena AN. Improving primary care quality now and into the next decade. Quality in Primary Care.18(6):357-358.
68Dawda P, Jenkins R, Varnam R. Quality Improvement in General Practice. London: The King’s Fund 2010.
69Georgiou A, Burns J, McKenzie S, Penn D, Flack J., Harris MF. Monitoring change in diabetes care using diabetes registers: experience from Divisions of General Practice. Australian Family Physician. 2006;35:77-80.
70Makeham AB, Kidd M, Saltman DC, et al. The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. Medical Journal of Australia. 2006;185(2):95-98.
71Furler J, Cleland J, Del Mar C, et al. Leaders, leadership and future primary care clinical research. BMC Family Practice. 2008;9(1):52.