TOC analysis of GP practice KPIs: Do they improve care or encourage local optimization?
The GP KPI framework has the same fundamental TOC risk as the hospital framework: individual measures can improve while the overall patient journey gets worse.
In general practice, the central challenge is to provide safe, effective, continuous care while managing limited clinical capacity, unpredictable demand, and competing needs.
The KPIs cover five important dimensions: safety, effectiveness, caring, responsiveness, and leadership. But they can create conflicts when practices are judged on individual targets without considering how those targets interact.
I will use the KPI descriptions as the basis for the analysis. The examples below identify potential unintended consequences, not evidence that a particular practice is gaming its measures.
1. Local optimization: Where GP KPIs can conflict
The global goal can be expressed as:
Provide patients with timely, safe, effective, compassionate, and continuous primary care, using available resources sustainably.
A. Access targets vs. continuity of care
Potential conflict
More appointments vs. seeing the right clinician
KPIs involved: Appointments within two weeks, same-day urgent appointments, phone-answer times, patient survey scores.
Local optimization: Maximize the number of appointments offered and reduce waiting times.
Potential unintended consequence: Patients may be directed to whichever clinician is available, even when continuity with their usual GP would be beneficial.
Global goal at risk: Coordinated, effective care, particularly for patients with complex or ongoing conditions.
TOC insight: Maximizing appointment throughput does not necessarily maximize the quality or effectiveness of the entire care pathway.
B. QOF targets vs. the patient's overall needs
Potential conflict
Meeting disease-specific targets vs. treating the whole patient
KPIs involved: QOF points, diabetes HbA1c and blood-pressure measures, asthma reviews, screening and immunisation targets.
Local optimization: Focus clinical time on patients and activities that improve QOF achievement.
Potential unintended consequence: Other needs—such as complex symptoms, mental health, multimorbidity, or care coordination—may receive less attention if they are not adequately represented by the targets.
Global goal at risk: Comprehensive, patient-centred care.
TOC insight: A disease-specific indicator is a diagnostic measure, not a complete measure of the patient's overall health.
C. Referral targets vs. appropriate clinical judgment
Potential conflict
Referral activity vs. the right care at the right time
KPIs involved: Cancer referral rates, waiting times, prescribing measures, and clinical outcome indicators.
Local optimization: Focus on meeting referral or prescribing expectations.
Potential unintended consequence: Clinical decisions may be influenced by the measure rather than solely by the patient's needs, if the target is poorly designed.
Global goal at risk: Appropriate, evidence-based care.
TOC insight: The purpose is not to maximize or minimize referrals in isolation. It is to ensure that patients receive the right assessment and treatment without avoidable delay.
D. Phone-answer time vs. clinical capacity
Potential conflict
Answering calls quickly vs. resolving patient needs
KPIs involved: Average phone-answer time, percentage of calls answered, appointments offered versus demand.
Local optimization: Reduce call-answer times by moving callers through the system quickly.
Potential unintended consequence: Patients may still struggle to secure an appropriate appointment or have to call repeatedly.
Global goal at risk: Timely access to effective care.
TOC insight: The time taken to answer the phone is only one part of the patient journey. The more important question is whether the patient gets the care they need.
E. Financial performance vs. clinical capacity
Potential conflict
Controlling expenditure vs. maintaining sufficient capacity
KPIs involved: Finance, staffing, training, appointment availability, and access.
Local optimization: Reduce expenditure to meet a financial target.
Potential unintended consequence: Insufficient staffing or limited appointment capacity can increase waiting times and workload.
Global goal at risk: Sustainable, safe, timely care.
TOC insight: Cost control should support the overall purpose of the practice, not undermine the capacity needed to deliver care.
2. Can GP practices game these KPIs?
Yes. The design of targets can create incentives to improve reported performance without necessarily improving patient outcomes. This can happen through legitimate prioritization, changes in workflows, or potentially inappropriate behavior.
Here are some risks worth examining:
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KPI
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Potential gaming or distortion risk
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QOF points
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Concentrating effort on rewarded indicators while less-measured patient needs receive less attention.
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Appointment within two weeks
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Offering an appointment that meets the target but is not with the appropriate clinician or does not resolve the patient's problem.
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Same-day urgent access
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Classifying demand in ways that improve reported access without ensuring that all urgent patients receive appropriate care.
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Phone-answer time
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Shortening calls or redirecting callers without resolving their underlying need.
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Antibiotic prescribing
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Focusing on a prescribing threshold without adequately accounting for clinical complexity or patient circumstances.
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Patient survey scores
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Focusing on satisfaction ratings rather than the underlying causes of poor access or continuity.
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Significant events logged
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Treating the number of recorded incidents as a performance target, rather than focusing on learning and prevention.
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Referral rates
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Interpreting high or low referral rates as inherently good without considering clinical appropriateness.
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The key distinction is between improving the metric and improving the outcome the metric is intended to represent.
A low number of reported incidents, for example, is not necessarily evidence of safer care. A practice that encourages staff to report and learn from incidents may initially record more events while improving its safety culture.
3. Uncertainty, conflict, and complexity in general practice
A. Uncertainty: Demand is variable, but access targets are often fixed
GP practices face unpredictable demand from acute illness, chronic disease, seasonal infections, urgent mental health needs, and patients with complex conditions.
A fixed access target does not tell a practice how to manage that variability.
Potential trap: Treating every day as if demand were predictable and trying to maximize appointment utilization.
TOC response: Identify the constraint in the appointment system, understand demand patterns and variability, and protect sufficient capacity to handle urgent and unpredictable needs.
B. Conflict: Clinical priorities vs. performance targets
A GP may need to choose between:
Seeing an urgent patient today.
Reviewing a patient with a chronic condition.
Maintaining continuity for a patient with complex needs.
Completing preventive care and QOF-related work.
All may be legitimate priorities, but they compete for limited clinical time.
Potential trap: Treating each target as equally urgent and expecting staff to meet all of them without resolving the underlying capacity conflict.
TOC response: Establish clear clinical priorities and align appointment allocation with the overall goal of safe, effective care.
C. Complexity: A GP practice is part of a wider healthcare system
A practice's performance depends on services outside its control, including:
Hospital specialist appointments.
Diagnostic services.
Community nursing.
Mental health services.
Social care and support services.
A GP may identify a patient's need and make a referral, yet the patient may still face a long wait for the next stage of care.
Potential trap: Judging the practice only on its own activity or referral measures without considering the complete patient journey.
TOC response: Identify where the patient pathway is constrained, distinguish what the practice can control from what it cannot, and coordinate improvement across the relevant services.
4. The GP access dilemma: An Evaporating Cloud
A simplified TOC Evaporating Cloud helps expose the conflict between rapid access and continuity.
A — COMMON GOAL
Provide timely, safe, effective care that meets patients' needs.
B — NEED 1
Ensure patients can access care promptly, especially when urgent.
C — NEED 2
Ensure patients receive appropriate, continuous, personalized care.
D — ACTION 1
Offer the next available appointment to reduce waiting time.
D′ — ACTION 2
Prioritize continuity with the patient's usual clinician.
THE APPARENT CONFLICT
Rapid access may appear to require sacrificing continuity, while continuity may appear to require accepting longer waits.
The assumption to challenge
The conflict depends on the assumption that every patient must be allocated either to the next available clinician or to their usual GP.
That may not be necessary.
A practice could potentially differentiate between:
Urgent problems that require prompt assessment.
Ongoing conditions where continuity is particularly valuable.
Routine administrative or preventive care.
Complex cases requiring coordinated appointments.
The objective is not to maximize continuity or access in isolation. It is to design an appointment system that delivers both where clinically appropriate.
This is a possible direction for improvement, not a claim that every practice has sufficient capacity to implement it without additional resources.
5. What would a TOC-aligned GP KPI system look like?
Rather than replacing the five CQC questions, I would connect them to a clear hierarchy of measures.
Level 1 — Global goal
Are patients receiving the care they need?
Measure safety, clinical outcomes, timely access, continuity, patient experience, and equity.
Level 2 — Patient flow
Where are patients waiting, and why?
Measure time from requesting care to appropriate assessment and resolution, including delays caused by referrals or other services.
Level 3 — Constraint indicators
What is limiting the practice's ability to deliver care?
Examine clinical staffing, appointment capacity, demand variability, telephone access, administrative workload, and referral bottlenecks.
Level 4 — Guardrails
Are improvements creating unintended harm?
Monitor prescribing safety, clinical outcomes, continuity, patient experience, safeguarding, and financial sustainability.
Five practical changes
Connect access targets to clinical outcomes. Measure whether patients receive appropriate care, not just whether they get an appointment.
Protect continuity where it matters clinically. Distinguish patients who benefit from a familiar clinician from those whose needs can be met by another appropriate professional.
Identify the true constraint. Determine whether the bottleneck is appointment capacity, telephone access, clinical staffing, administrative work, or an external service.
Use QOF as a diagnostic tool, not a complete definition of quality. Ensure that disease-specific targets do not crowd out broader patient needs.
Measure the whole patient journey. Track unresolved needs and downstream delays, not just activity completed within the practice.
6. The most important TOC insight
The GP KPI system risks confusing activity with achievement.
More appointments do not necessarily mean more problems resolved.
Higher QOF scores do not necessarily mean every patient receives comprehensive care.
Faster telephone answering does not necessarily mean better access.
Fewer reported incidents do not necessarily mean safer care.
A balanced budget does not necessarily mean the practice has enough capacity to meet patient needs.
The central question is:
If a GP practice improves this KPI, does the patient's overall health and care experience improve—or does the problem simply move somewhere else?
Bottom line
The five CQC questions provide a useful framework for assessing quality, but the individual KPIs can encourage local optimization if they are treated as independent goals.
A TOC approach would connect them to a shared global goal, identify the constraint limiting patient care, and align appointment allocation, clinical priorities, and resources around improving the entire patient journey.
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