Tight budgets mean PCTs must scrutinise all contractors to ensure they are providing the right value and quality of services - and this includes GPs. Graham Clews looks at the role of the balanced scorecard

  • PCTs are having to review the level of service they are getting from GP practices.
  • The balanced scorecard tool attempts to combine quality and efficiency indicators.
  • GPs’ concerns include publication of the scorecard data without agreement by the GPs.

A mix of the financial pressures ahead and the drive to improve how well primary care trusts commission has put greater weight on the need to increase the value provided by GP practices.

At least primary care trusts have had some warning. They know they are going to have to make savings and seek value for money as the recent huge funding increases to the NHS begin to dry up. Managers will want to increase efficiency and effectiveness across the patch and if commissioners want to continue to shift treatment from secondary to primary care then value for money in the primary care sector will be vital.

The NHS spends around £8bn on GP services each year. Until now, quality and access has been a high priority, significantly ahead of the effort focused on productivity.

This requirement for PCTs to performance manage GP practices has manifested itself in a curious hybrid of both value and quality: the balanced scorecard. The balanced scorecard is designed to bring together various performance indicators already in existence for GP practices, such as access surveys, patient surveys, and the quality and outcomes framework of the GP general medical services contract. It can supply information for the general public to serve the choice programme and, importantly, be a tool for PCT management.

In its paper Commissioning in a Cold Climate, published in June, the NHS Confederation reported on PCT commissioners’ concern that as budgets diminish, efficiency and productivity gains would have to accrue to the PCT as cash.

Commissioners say it limits their ability to spend less on primary and community health services because, for example, the cost of core GMS contracts cannot be reduced locally, even if practices can work more efficiently and reduce their own costs.

The confederation document recommends: “In the case of general practice, PCTs need to review the level of service they are receiving under the core contract, and whether the enhanced services they are paying for are providing sufficiently increased value.”

Commissioners want policy makers to be more explicit about the range of acceptable standards of service provided under the national primary care contracts.

The document also recommends that standard NHS contracts (including primary care) be reviewed “to identify other ways of encouraging providers to find cash-releasing efficiencies”.

“In particular,” it adds, “a more explicit statement of what is included in the core GMS contract is required as well as a performance framework that enables PCTs to more clearly identify the value they derive from core and enhanced services.”

The document points out: “Some PCTs have developed primary care performance frameworks and are using these to clarify their expectations and drive up quality.”

But it warns that clinical ownership is central to strategies for reducing costs and improving the efficiency of health services.

Some resistance

This is the happy middle ground that PCTs have to find in the face of some resistance to the use of balanced scorecards among GPs.

In NHS Westminster, for example, GPs on the PCT’s commissioning executive committee expressed concerns about data being published without the agreement of the practices. But the PCT’s chief executive told doctors on the committee that it would press ahead with publication anyway.

British Medical Association GPs committee chair Laurence Buckman says balanced scorecards are now part of the Department of Health’s world class commissioning programme, “so it’s going to happen”.

But he adds that in his and many other GPs’ view they are misleading because, despite the name, they are not balanced.

“They are producing various indicators and then just adding them up to make a kind of pseudoscience,” he says. “For instance, you cannot compare what my patients think of me with whether or not the toilets in my practice are Disability Discrimination Act compliant. They’re both important, but they’re not the same.

“Balanced scorecards so far also tend to include political things like bits of the access targets that are not what patients or doctors, or even managers, want, but are what the government wants. They are turning the idea of better commissioning of primary care, which is fine, into a league table.”

Improvement tool

Ken Aswani, national professional executive committee chair lead for the NHS Alliance, and also for NHS Waltham Forest in north east London, says there is now a broad acceptance among GPs in his PCT that balanced scorecards are here to stay.

The information they provide has significantly driven up standards and improved quality, he believes, but he warns that PCTs must not be tempted to weight the scorecards towards efficiency, rather than quality, if money is tight.

“Fundamentally it has to be about improving patient care and indicators must reflect quality rather than just efficiency,” he says.

As the scorecards become more sophisticated their uses may become wider, but he argues that they must not be used for financial discrimination against badly performing practices.

“Change in performance obviously uses both carrots and sticks, but we have to be careful there is not disengagement with a large number of practices,” he says. “If the scorecard is used in a punitive way it could produce a very negative reaction among practices.”

So far, the scorecard has worked well as an improvement tool for practices on Dr Aswani’s patch, with GPs learning from other high quality practices, and practices that score well across most indicators left largely to manage their own improvement in areas of poor performance, with only a light touch from PCTs. Where practices have performed consistently poorly across a number of indicators, and have shown no sign of improving within a reasonable timescale, the PCT has had to intervene, but the situation has often remedied itself with GPs retiring early, or joining another practice.

Dr Buckman says most local medical committees already have a system for working with PCTs to support practices that need help. Where practices are struggling, particularly with financial constraints, this can be used to improve performance.

“I don’t think PCTs will use balanced scorecards as a way of getting GPs to do more work for less money, but they may use them as a tool to determine where they will invest,” he predicts.

But he warns PCTs must be aware of the limitations of the scorecard system: “We have to make sure PCT managers understand the limits of the data they have.”


More information is being produced for PCTs. Commissioning Support for London, for example, has produced its online provider performance analytics tool for commissioners to monitor how providers are measuring up, and to monitor contracts.

Although mainly aimed at secondary care providers, the tool includes data on PCTs’ performance in the ability to see a GP within 48 hours, patient satisfaction with practice opening times, satisfaction on telephone access, and other primary care benchmarks.

Lead for this product, Christopher Johnston says: “The portal will help PCTs work towards a better quality of commissioning by benchmarking pan- London performance, identifying underperforming areas and sharing pan-London best practice.”

NHS support service Primary Care Commissioning has produced its own guidance on managing GP practices through the balanced scorecard, and lists different ways for PCTs to take action. It talks of PCTs’ “formative and facilitative” approach, but says that where there is a lack of co-operation for improvement, or lack of progress, the PCT can use its commissioning powers, which can include removal of the contract, to require improvement.

It proposes assessment across eight areas: statutory contractual requirements of the GMS or personal medical services contracts; environment and infection control; access; range of services; quality of services; both clinical and cost effectiveness of prescribing; and patient views.

Forty-one types of support for practices are proposed, including training teams to support quality and outcomes framework visits; occupational health service access for GPs; liaison between the PCT and local medical committee; targeted visits at practices causing concern; ad hoc seminars; and even touch typing courses for practice staff.

Where a contract may have been breached, the PCT can give the practice time to remedy the breach, introduce contract sanctions or terminate the contract.

PCT Network director David Stout says the lack of specific wording on the core services expected under the GMS contract has contributed to the variation in quality and level of practice services around the country.

For instance, some practices will provide treatment for patients with diabetes, whereas some will move them on to secondary care, but the contract is silent on what kind of care should be provided.

“There are obviously clinical reasons for the different type of care that practices can offer,” he says. “But the contract has no specifics on individual illnesses, so PCTs get different services for the same investment.

“As times get harder, questions will have to be asked on what PCTs are getting for their money. Most PCTs have developed or are developing a balanced scorecard, although there is a lack of a national template; and while it is mainly to do with quality, clearly people will be thinking about productivity.”

The debate among PCTs in straitened financial times will be whether to go to secondary care, and that could mean PCTs commissioning more services from GPs, rather than fewer.

Mr Stout says PCTs will have to look at what is being provided through enhanced services and PMS contracts, as well as considering what national negotiation is going to deliver on the core GMS contract.

But as funding becomes less generous PCTs will have to ensure they get the return they need on the money they are spending.

“You can’t rule out greater investment in general practice, but PCTs will be looking to see what the best GPs are doing and looking at who is providing the most effective and efficient care,” says Mr Stout.

“It is the art of the possible.”

Stop at red: NHS Harrow

NHS Harrow introduced its balanced scorecard system in October last year. The PCT uses the quality and outcomes framework, patient surveys and premises surveys to determine the level of quality service provided by each practice.

Practices are assessed against 15 quality indicators within seven domains.

One mandatory domain measures on a simple yes/no basis whether the practices are meeting contractual requirements set out in the GMS contract.

Other domains - which receive green, amber and red lights - measure access, including opening hours and telephone bookings, and the range and quality of services provided (using QOF scores).

On the latest available figures, the worst performing practice has seven red lights and two amber lights across the 15 indicators, and one practice has been rated with five red lights and two amber lights.

Of the 38 practices, 25 received at least one red light, although no practices were given red lights in the contractual requirements category.

Only one practice scored green lights across the board, and the PCT says that for the highest performing practices it seeks to agree additional incentives for enhanced performance. These “stretch targets” will encourage practices to perform over and above the highest standards expected by current systems such as the quality framework.

Where a practice is amber or red for any indicator the practice is required to provide an action plan detailing their plans for improvement towards “best practice”. The PCT and the practice will agree a series of timetabled improvement milestones and the PCT will provide support and advice on how best practice can be achieved. This can include: extra training for clinicians or practice staff; sharing of best practice examples between practice managers; expert advice from PCT staff on HR, IT or patient involvement issues; or PCT facilitated peer support from other GPs, practice nurses or practice managers.

Only when a practice is not meeting an acceptable standard of service, and sustained development support is not working, will the PCT consider formal contractual action.

If practices score red for either the contractual requirements or environment and infection control domains, or if the overall level of service provided by a practice is deemed not to meet an acceptable standard and so not to meet the terms of the contract, the PCT will consider issuing a remedial notice. This will require the practice to make demonstrable improvement within a specific timeframe. In these cases, the PCT will inform the local medical committee at the beginning of the process to ensure that the practice has access to all necessary support to make the required improvements.

Termination of a contract will only be considered in extreme cases where “there is a sustained lack of co-operation or lack of progress in the agreed timeframe”, and to date no termination notices have been issued.

NHS Harrow chief executive Sarah Crowther says the balanced scorecard “provides an opportunity for GPs to work together with NHS Harrow in ensuring constant improvements in the quality of care patients receive. It is one of the methods we are using to secure patient choice, provider accountability and a more accessible health service in Harrow”.