Most of the GPs interviewed supported the development and implementation of quality markers for children in UK general practice. Quality markers were seen as important for assessing the current standard of paediatric primary care and improving its future quality. However, they were concerned that they would be judged on outcomes which they felt powerless to influence. It certainly makes no sense to judge GPs’ clinical performance on the basis of outcomes unlikely to be influenced by their clinical activity. It is also important that any quality indicators adopted enjoy professional support.
There was an expressed preference for quality markers based on outcomes rather than on structure and process. However, when pressed to suggest possible markers they often went on to say paradoxically that most important health outcomes are influenced little by the quality of primary care. Consequently, many of the specific quality measures proposed by the GPs were related to process rather than outcome. This paradox is also reported by researchers in the US who noted that the development of outcome-based quality markers for children is particularly challenging because children’s health is affected by so many issues other than the quality of medical care
. A good example was the views expressed about emergency admissions. While many saw this as an important outcome which reflects quality, many participants also commented that such admissions in children are due to numerous factors over which GPs have little control (and the evidence supports this view
[10, 31]). The balance of opinion expressed was therefore that emergency admissions could not be used as a quality marker for the care of an individual practitioner.
While several quality markers for specific clinical conditions were suggested by participants, no consensus emerged about the most important. Quality markers for a number of the conditions proposed have already been developed by non-UK organisations such as the RAND Corporation and the Agency for Healthcare Research and Quality
[32, 33]. However, notable gaps remain, particularly for topics such as training. Certain initiatives have already commenced to address this gap including the RCGP First5 initiative
[34, 35]. The new National Health Service Outcomes Framework for 2012/13 also includes health improvement targets aimed at reducing unplanned hospital admissions for children with select chronic conditions (i.e. asthma, epilepsy and diabetes) and select lower respiratory tract infections
The potential to develop quality standards for access to care was mentioned by a number of participants. Although this has been a major focus of primary care reform in the UK over the past decade (which included the introduction of ‘Advanced Access’ and setting a target that general practice had to provide an appointment within 48 hours) success in addressing access barriers has been modest
. Lack of easy access to primary care may partly explain the rise in ED visits for children in England
. However, access is not an issue specific to children and development of any quality marker would need to avoid adverse consequences for other age groups. The potential for unforeseen adverse consequences of setting quality markers was raised by a number of participants and has been recognised as a good reason for piloting before national roll-out
A number of participants also raised the potential for quality markers to increase social inequality, in one case citing the Inverse Care Law
. While the potential is clear for financial incentives based on quality markers to penalise under-achievement caused more by the social deprivation of the practice population rather than the quality of clinical practice (e.g. teenage pregnancy or smoking rates), recently published evidence based on existing QOF markers shows very little systematic difference in achievement of targets in practices in relation to the population deprivation index
[38, 39]. However, there is a potential to use quality markers as a mechanism to target social inequality in general and specific groups of children at high-risk of ill-health in particular. Only one of the participants specifically suggested such an approach (setting a quality standard for follow-up children that fail to attend appointments) but it clearly is feasible to develop quality markers for ‘at risk’ children to ensure they have a planned proactive review of their care
A potential criticism of the study is the limitation of the sampling frame to the Oxford health region and the likelihood that the general practitioners volunteering to participate had both a particular interest in child health and an enthusiasm to improve care quality. It is therefore possible that we did not identify some views held only by general practitioners without such enthusiasm (who might have been more strongly opposed to the idea of quality markers for care of children). Moreover, general practitioners are not the only clinicians providing care in a community setting and ideally we would have extended the study to include other health professionals (e.g. health visitors, practice nurses and reception staff) and perhaps parents. Nevertheless we did achieve data saturation and identified a wide range of important issues and opinion which should inform quality marker development.