One of my favorite parts in the journal BMJ is the occasional column written by Dr. Iona Heath, the president of the Royal College of General Practitioners. Her thoughts have helped me understand the similarities and differences between the U.S. and British physicians, healthcare systems, and culture. And I love her blunt statements.
The subject of a recent column was a report by the King’s Fund (an independent charity that studies and comments on the British National Health Service) on the quality of care in general practice. Of course, the report concluded that the world of the general practitioner could be better – anyone can imagine a better future. Dr. Heath had several comments on the report, and I will highlight two of them here.
One of her overall reactions was that she felt the report demonstrated “… how intensely difficult it is to undertake the general practice care of patients day in and day out,” though this conclusion was not explicitly stated. One example she gave was that the importance of continuity of care was covered in the report, though one of the lead authors “… noted with regret the failure to include any reference to continuity in the recommendations.” Other comments in the BMJ the last few years have bemoaned how the pay-for-performance Quality and Outcomes Framework (QOF) program has harmed doctor-patient relationships in its efforts to define high quality care as a series of checklists.
The comment that really caught my attention was when she noted that the report implied that “… patients are presented as units of health need, indistinguishable but for their medical histories. They are assumed to be uniformly rational and committed to making decisions designed to promote their health, only to be obstructed by those they encounter working in the NHS: in this case their GPs.”
She goes on to say about the report, “I find no evidence of any understanding that patients can also be abusive, manipulative, and self destructive.”
I share her frustration on this side of the pond with American bureaucrats and well-intentioned think tankers. None of the standard views of quality improvement recognize that patients sometimes don’t want to do what we’d like, but we keep caring for them anyway. None of the quality report systems allow us to tell the computers when we have a very good reason to not follow a standard guideline (the UK QOF does allow this). None of the suits stand ready to support family physicians when we are pressured by “empowered” patients to order tests are treatments we believe to be unnecessary or wasteful.
The world of government and business is used to thinking with metrics and measurements. Large employers put pressure on insurance companies to prove they are providing quality care, so the companies invent metrics that are chosen more because they are easy to measure with existing resources than other considerations of costs and outcomes. If the payers of healthcare want it to be less expensive, they need to help us develop new measures that capture the complexity and difficulty of providing comprehensive primary patient care.
“I find no evidence of any understanding that patients can also be abusive, manipulative, and self destructive.”
Can you imagine the uproar if the head of any American medical organization dared to be so honest!
What is truly deplorable is that the AAFP continues to insist, without any supporting evidence, that P4P measures be part of payment reform for family physicians. As always, one wonders whoseinterests are they representing?
I think some form of P4P makes sense, but we don’t know how to do it yet. It’s really simple: if society — the government, insurance companies, advocacy groups, ologist societies, the media — want us to do more stuff to people in an office visit, we must be paid for the time it takes to do more work. A better system of quality accountability has two components: fair pay for the time to do more cognitive work and a reporting system that let’s us say why a checklist expectation was not met.
What you describe is a logical approach. What is incomprehensible to me is the AAFP pushing discredited as currently designed P4P programs as part of their 3-horned payment reform scheme. That benefits neither patients nor physicians. Who does it benefit?
My patients do indeed fall into two categories: those that want to do everything and always have heard of a new test they just have to have and then those that don’t want to do anything. I am in the middle of the two groups and sometimes I just don’t know what the best option is.
Yes, what we do is actually very complex and often doesn’t fit into neat categories.