The problem with usual care.

The problem with usual care in general practice is its variability. UK GPs often provide care to rival the best in the world, but not always. For example, the report of the pilot study for the Child Death Review cites examples of general practice care of which we should be proud, but it also reveals poor care which contributes to avoidable death. 1 Between these extremes, there is a gradient of care of variable quality. The systematic review of usual care for back pain reported by Somerville et al on pages 790–797 provides a good example, showing substantial differences in the clinical approach to a common condition even in selected practices involved in clinical trials. 2 As the authors say, usual care is variable in content and effectiveness. Reducing the variability in usual care is certainly a good thing in clinical trials. Proving that a particular method of managing back pain is better than usual care doesn't help much if what was provided as usual care is unclear. The authors' recommendation that papers reporting clinical trials should more fully describe the usual care delivered is uncontroversial but insufficient. 2 GPs involved in such trials need to reach agreement about the content and delivery of best usual care before they start the research. Even if the usual care provided is fully described in a research paper, interpreting the results and applying them to your own clinical practice is very difficult if what is reported is a wide spectrum of care of variable content and quality. In everyday clinical practice, variability in usual care matters most at the tail-end of the distribution where poor care can lead to adverse outcomes including avoidable death. Although effective regulatory mechanisms to deal with poor care are essential, epidemiological studies suggest they are likely to be less effective in dealing with a tail than trying to shift the whole distribution by driving up average performance. 3 The UK Quality Outcomes Framework (QOF), a protocol-driven pay-by-performance incentive scheme for GPs, already appears to have contributed to this aim for two chronic conditions. The mean practice quality score for diabetes and asthma increased from 70% to over 80% in 2003–2005. 4 The variability of usual care was also reduced, with progressive decreases in the upper limit of exception reporting 5 and in inequalities in the delivery of care. 6 Although there will now be pressure from NHS policy …