status quo of quo vadis? - KCE

KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 31
secondary care and community health care services for their patients. GPs were the
principal locus of spending money in the health care system.
In 1998 there were 3500 GPFHs. 80 Fund holding was abolished by the incoming Labour
administration in 2000, but a similar form of primary care purchasing is now being reintroduced
under the name ‘practice based commissioning’. According to public health
experts, this will give to general practices and Primary Care Trusts a substantial control
over the funding of hospitals and specialist care.
Since April 1999, all GPs have been required to join a primary care group. These large
area based groups of GPs have responsibilities for providing primary care. However,
113, 80
this does not alter the individual contracting of GPs with the NHS.
Commercial insurers face increased competition. The number of private hospitals is
increasing. The private sector greatly increased in size recently, partly because the NHS
now contracts some services from the private sector (mainly specialists). The number
of GPs in private practice is still low and they mostly work in urban London. 80
GPs are self-contracting with the NHS. The payment system is a mix of capitation fees
(based on the size of the patient list) and fees for specific services. These last ones
include health promotion payments for achieving targets (i.e. cytology screening) and fee
for service payment (i.e. minor surgery).
A new contract (introduced in 2004) aimed to reward practices for care of high quality,
to improve GPs’ working conditions and to ensure that patients benefit from a wider
range of services in the community. 113 The actual income of a GP is therefore
dependent on the patient list size, specific services (e.g. pap smears, minor surgery) and
points achieved in the Quality and Outcomes Frameworks.
2.4.4.2 Quality development in action: culture, legislation, financing, organisation and
implementation
NATIONAL BODIES AND LEGISLATION
A prominent feature of the UK system is a strong emphasis on measuring and improving
quality standards. New agencies were set up, including the National Institute of Clinical
Excellence (NICE). This organisation produces guidelines on appropriate treatment and
care of people with specific diseases and conditions within the NHS. 114 Furthermore the
Healthcare Commission, also independent, is the inspection body and the ‘health
watchdog’ of UK. It checks that healthcare organisations are meeting standards in a
range of areas including safety, cleanliness and waiting times. They use for 32 core
national minimum standards. 115
In 2002, The Royal College of General Practitioners issued basic presumption on the
use of quality indicators. 116 In 2004, they published a paper to detail the current UK
system of general practice that can offer equity of access, quality of care, and economic
efficiency. 116
GUIDELINES AND AUDIT
NICE is the main national institution that develops and publishes guidelines. From 1991
onwards, GPs had to perform mandatory audits every four years. 40 However, this
theoretical requirement had no time scale and has never been interpreted or
evaluated. 85 The validity of auditing has been debated. The review criteria were not
standardised. 47 Moreover, the overall effectiveness of audits on actual care raised
question. 41 Nevertheless, the UK auditing system is a powerful mean of setting
standards and stimulating quality initiatives in groups of GPs and primary care
organisations in general. 40 The Audit requirements have now been replaced by the
requirements of the QOF scheme.