One of the more insidious changes in clinical practice in primary care was the introduction of performance-related payments in a big way in primary care. This whole idea is predicated on the fact that professionals will only practice good quality medicine if there is a carrot at the end: doctors as donkeys.
The system chosen in 2004 was the Quality and Outcomes Framework (QoF). What Government decided to do, in a raft of changes to the contract, was introduce this idea as an incentive to help improve clinical care. I can see the logic behind this in that there were some very poor practices who were not practising medicine to an adequate standard. Other measures included an increase in pay (to catch up) and the first privatisation - that of GP out-of-hours services.
Jobbing Doctor accepted this contract, flawed though it was.
There are certain outcomes that have occurred as a result.
Firstly, Government underestimated the amount of high quality medicine taking place in primary care at that time, and so did not budget for it (despite being told repeatedly). This saw GP income increase by around 33%. Practices like mine had no difficulty in hitting the targets - we were there, pretty much, already.
Secondly, performance measures were always a very crude measure of clinical excellence, and therefore - as a valid measuring tool - had significant flaws. I have seen this.
Thirdly, it encouraged gaming with the system. Some GPs, whose practice income depended on hitting targets, would be tempted to distort the measures and also (on occasions) invent data. I have seen this happen in my locality (but not in my practice).
Fourthly, the focus would be on conditions in the QoF areas and other conditions - outside this system - may well get less attention.
Remember that I am a functionary. A lowly cog in the system of healthcare, and I have to do what I am told by Government. These decisions were pushed through by Government. Some good has come, with more efficient control of Diabetes and Hypertension giving better long-term outlooks for those patients.
But don't get the idea that Performance-related pay is a success.
The other downside is that ideas like the QoF diminish a profession's values and judgements, meaning that high quality care is not driven by an internal motivation for doing a good and valuable job well, rather we have to be driven by targets.
Targets are the antithesis of professionalism.
Discuss.
Reposted from the archive.
Reposted from the archive.
14 comments:
Snap:
In a recent post I said:
Look at what happened to Out Of Hours service and hospital weekend and holiday manpower levels and you will know what I am talking about.
Unfortunately, it may be too late to try and bring back the good will that has kept the OLD NHS going for so many years. The good will that was slowly destroyed by modern management ways and silly Pavlovian bonus culture.
“Please, spare us.”
Oh dear - once I get started on targets and how much damage they do, I can't really stop - but keeping it as brief as I can and within my own sphere of operation (social work), I can't express how much damage they have done to quality work. The people who set the targets are so far removed from practice that they have been set over some of the less relevant data sets - leading to a poorer service. Everything is quantified and counted although working with people - and professional judgement is chipped away until we are all turned into drones - working to targets, working to targets.
I am happy for all my work and my time to be accountable. I want to be accountable but not based on meaningless targets dreamt up by project managers and management consultants.
(and that's my tame version!).
I am not trying to defend pay-for-performance schemes. However, it has been become widely adopted as a method of calculating a clinician's compensation. If we were to do away with this pay-for-performance system now, would GPs that are making 33% more complain and fight to keep the status quo? I know that if my pay was cut by as much as 33%, I would fight to keep as much of it as possible.
So, I guess my question is really this...How do you propose we fix the inadequacy of target based medicine (if it is even salvageable)?
Another question around under-performing clinicians (which is sure to rouse some debate)...
Which is better?
1) bonuses to high performers
2) take away pay from under-performers
top down targets are indeed a poor way of managing anything
even a fire chief managing the biggest fire listens to what his troops say, and will react to the customers pointing out another fire
the only targets worth anything are customer satisfaction targets, which in your case can be measured
i) what the customers say
ii) how long they live
and their quality of life
and let the customers choose any medical provider and support the providers than get the most customers, this dynamic will force cleaner sites, opening hours reflective of the patient needs, docs who can communicate clearly in english, and so much more
Thank you for this post. Wise words.
Think yourself lucky that in general practice they employ the carrot. All we get in the Hospital side is the stick
promoting target reaching seems to be another way to reduce the volition or 'elective preference' [thankyou wikipedia] out of the profession, promoting movement towards a less skilful algorithm based method of care, which will debase doctors skill sets and produce more rigid and less tailored care to the patient, leading to poorer treatment outcomes and thus satisfaction. However I guess on the flipside, less rigid and more qualatative targets might work, but I do not see how they could be cost effectively or quantatively judged.
no one -
"the only targets worth anything are customer satisfaction targets"
hmmm, would beg to differ on that one. How satisfied do you think patient's are when they don't get the antibiotic they demanded for a viral illness for example? Or the sick certificate they don't need?
Echoing Coackroach catcher and with reference to Sick Notes - that you are reading - I also feel that it is now too late to bring back the "OLD NHS" where professionalism (motivated by altruism, benevolence and charity) held sway and where (predominantly pale, stale and male) doctors knew their stuff and could be trusted.
As "Tony Copperfield" relates in Sick Notes today's medical students may have better communication skills but lack basic knowledge.
If then old school , jobbing doctors are disappearing ( too fast) and are being replaced by well meaning but confused (and ignorant?) functionaries - perhaps the top down targets, protocols and check lists will be a neccessary evil.
However - for what its worth - for old school patients, as well as old school doctors, this extended transition from OLD to NEW is a real pain.
It seems we must all accept the NEW NHS (a "market" hotch potch based on voodoo economics) and move on from a much loved service that worked (and provided continuity of care)to a much criticised one that patently fails to meet the needs of an ageing population with multiple co-morbidities and complex polypharmacy.... Shame!
JD, r u back from Sri Lanka yet?
If u r u r driving me nuts! This archive nonsense is driving me to look elsewhere for the solace of GP lovliness!
I notice your blog still appears in Pulse.
NSSmug
So, this is all about money JD?
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