In England primary care groups will have a key role in promoting the health and improving the health care of their local population.1 By April 1999 these groups, involving all primary care professionals, will provide and commission health care for roughly 100000 people in each locality. Primary care groups will be accountable to health authorities and “will agree targets for improving health, health services and value for money.”1 There will be several primary care groups in each district health authority. This new approach offers primary care the opportunity to further integrate health promotion and health care at the individual and population levels.
The present UK government intends to manage the performance of the “new NHS”; the word performance appeared 88 times in its recent white paper.1 It has published a national framework for assessing performance as a consultation document,2 and primary care groups within health authorities will be judged to have “performed” well on the basis of the indicators listed in table table1.1. Most are attributable in part to primary care, but only some are linked to interventions that will necessarily lead to improved health outcomes. The government has also proposed four targets for England in its green paper Our Healthier Nation.3 Approaches taken by health authorities, and presumably by primary care groups, will be “fully monitored by the Regional Offices of the NHS Executive.”3 These targets for reduced death rates from heart disease and stroke, cancer, suicide, and accidents are all outcome indicators but, again, are only partly attributable to primary care.
- The NHS Executive and Department of Health have proposed a wide range of performance indicators many of which are applicable to future primary care groups
- Some of these indicators reflect access and efficiency, but few of the effectiveness indicators are based on primary care interventions for which there is evidence that increased uptake results in improved health outcomes
- We present a method to identify important primary care interventions of proved efficacy and suggest performance indicators that could monitor their use
- Our evidence based approach may be a complementary way of identifying areas for performance indicators to those proposed by the NHS Executive and Department of Health
- Our suggested indicators are more likely to help turn evidence into everyday practice and to have an impact on the population’s health
Performance indicators for practices
—Previous governments have attempted to use performance indicators for group practices of general practitioners, such as those linked to payments for uptake of immunisations and cervical smears. Health authorities have also tried to use practice based performance indicators,4 with varying degrees of success.5,6 The recent availability of data on prescribing analysis and cost has allowed health authorities to look at practice prescribing in more detail and to develop indicators reflecting “good and bad” prescribing.7 Campbell et al have identified a number of valid practice indicators from over 240 under consideration for use by health authorities in England and Wales.8
Performance indicators for primary care groups
—To maximise their usefulness, performance indicators for primary care groups should meet certain minimal criteria before any consideration of their introduction into routine use. They should be attributable to health care,9 sensitive to change,10 based on reliable and valid information, precisely defined, reflect important clinical areas, and include a variety of dimensions of care. The US National Library of Healthcare Indicators describes several “definable, measurable and improvable domains of performance” for its indicators.11 These are attributes of organisational performance related to “doing the right things” (such as appropriateness, availability, and efficacy) and “doing things right” (such as effectiveness, efficiency, respect and caring, safety, and timeliness).11 For those indicators that reflect appropriateness, availability, efficacy, and effectiveness there should be robust evidence that the interventions on which they are based lead to improved health outcomes. Use of such indicators to monitor performance may be one way to promote the wider use of evidence based interventions—for example, in the secondary prevention of coronary heart disease.12,13
However, there is more to primary care than the use of evidence based interventions. Other important dimensions to primary care include consultation skills, the advocacy role of members of the primary care team for individual patients, communication within the practice team, access to primary care, managing a business within a regulatory framework, and coordination with community, secondary care, and local authority services. The use of evidence based interventions and related performance indicators as presented in this paper can therefore only represent some aspects of primary care. Further research is needed to address the feasibility of developing meaningful performance indicators reflecting these other dimensions.
The aim of our study was to develop a method to identify important, evidence based interventions in primary care suitable for linking to performance indicators for primary care groups. Our objectives were to (a) identify interventions of proved efficacy for which primary care teams have a key responsibility; (b) estimate the number of preventable deaths or events in a primary care group locality of 100000 people if all those eligible were receiving the intervention; and (c) compare the potential indicators we derived with the indicators currently proposed by the government.