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Giving GPs 'cash for diagnoses' is unethical

NHS England’s new dementia enhanced service ‘crosses a line’ by paying GPs directly to make a diagnosis, argues Dr Martin Brunet

We need to think very carefully about this DES, as it crosses a line that has not been crossed before – the direct payment on the basis of making a diagnosis: ‘cash for diagnoses’.

We are used to being paid for items of service under QOF, but what is unique about the diagnosis is that patients have to trust us – they cannot opt out of it like they can with aspects of QOF, for example, declining to take a statin or come for an asthma check. You can’t ask to be exception reported from a diagnosis. Patients are at their most vulnerable when we make a diagnosis, because it is the doctor’s judgement and so very difficult for the patient to challenge it.

The payment is not on the basis of caring for our patients, but only the diagnostic label we apply – this creates a major conflict of interests that is frankly unethical.

Should we declare this interest to the patient when we make a diagnosis? If an insurance salesman were to make more money selling us one policy over another we would expect them to be transparent that it had financial implications for them.

And what about misdiagnoses? If we decide that someone has been misdiagnosed with dementia and remove that erroneous label then it will cost us £55 to do that.

Dr Martin Brunet is a GP in Guildford and director of the Guildford GPVTS

Readers' comments (8)

  • Ivan Benett

    This is an interesting assertion, and I'm not sure I'd agree. Certainly the ethical issues are rather complex.
    I would probably put the counter argument. It is unethical not to make the diagnosis in someone who would benefit, and the benefits can be substantial. Of course there are harms that need to balance the case, and the impact on autonomy needs to be taken into account. I don't think that the principle of universal justice is affected, although there is undoubtedly a cost to society in making the diagnosis (£50).
    The issue of payment is simply a transaction that has been agreed locally and is, of itself, not an ethical issue, unless it diverts resources from more worthy endeavours. To make a diagnosis because of the payment, in the absence of a justification for doing so, is simply unprofessional and probably illegal (fraud)
    Where a diagnosis of dementia is unethical is if they don't have dementia. Where someone has dementia it is probably unethical NOT to make the diagnosis. I suspect this payment is simply recognition that the GP has extra contractual work to do in order to case find and begin interventions.
    The challenge in diagnosing dementia is for us to move out of a medical model of care to a social one, and recognise the benefits or early diagnosis.

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  • Ivan Benett

    Ok ok £55!

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  • John Glasspool

    Hmmmm.... not sure I'd agree with that. We had "cash for minor ops and joint injections". I like to think that my PROFESSIONALISM was the thing that stopped me doing any of these unnecessarily.

    And in any case, £55 subject to tax and NI and superan, doesn't amount to much , does it?

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  • Vinci Ho

    (1)I can see people will come up with a criticism ,' we just cannot win with you guys , you moan with or without money anyway!'
    (2) But, always a but, what is the real meaning and motive behind this DES. Yes, if we carry on 'business as usual' , this £55 per patient could be a 'generous ' reward for those new cases we will pick up normally until the end of April next year.
    (3) Bottom line of this government is it believes that dementia is grossly under-diagnosed and wants majority of them diagnosed in the next 6 months.
    (4) In fact , practices will have to show a 'net increase ' in number of new cases before this money will be paid .
    (5) Virtually, this is a screening program with no adequate funding. Bear in mind , one will have to target a population and keep asking whether these patients have a memory problem , at least opportunistically. So 68 years Mr Jones saw me for chest infection , I would ask 'do you think you have concerns with your memory?'
    (6) While you are paid only for positive diagnosis ,£55 per case, Wow, effort and time have been spent on reassuring patients with a negative test result on mental health tests( whichever scale one will use).
    (7) Also , while it matters the most to pick up those with early stage of dementia as they may benefit from cholinesterase inhibitiors/Memantine, one will also pick up a lot of more advanced cases which actually need more input from mental health and social services. Are they properly funded for this extra work? This is where the question of being unethical coming from.
    (8) Once again , this is a ill thought campaign where politicians are running out of time for their political agenda . Another Giant White Elephant , new emperor's clothes.A little bit of money left on the road to pick up with an incoming truck coming towards you!(Copyright of John Glasspool!).
    (9) For those who wants to help these shameless politicians to accomplish this 'mission' , good luck. As I said before , it is only a fine line between politically correct diplomacy and dangerously flawed hypocrisy .
    (10) By the way , I am one of those crazy guy who does not sleep 4:00 am in the morning but I don't want to smell the coffee as I never drink it . And , of course , I am a die hard LFC fan , ha ha ha!

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  • Great arguments for and against and above comments make some very interesting points.
    My concern is - why Dementia? The lady in the discussion in BBC news at 6 am this morning commented that there are some real good drugs coming out and they would certainly help people with dementia.
    OK, so it would seem that the main aim could be a thrust towards boosting sales of drugs and the whole exercise may actually be aimed at a pharma co. No conspiracy theories but it begs an explanation, why not for case findings of other diseases. And would it be possible to look into who the decision makers are and have they any declared interests.
    My greatest fears:
    1. We may have overdiagnosed Dementia's like we had overdiagnosed asthmas when prevalence payments were introduced.
    2. Do we really have the funds if we diagnose a hundred thousand dementias at 55 pounds per patient? If yes, there is no crisis in NHS.
    3. Public perception of GPs as greedy money minded professionals whose main interest is that greasy crumpled banknote.

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  • Surely to screen and make diagnosis one needs to have an intervention that has some benefit to the patient. Do we actually have evidence for this?
    If not why is this a priority? We all should as we age anyway put in place POA/wills etc this probably is more useful advice to people who have not thought about such important issues rather than actual early diagnosis. As along with this comes some planning and thoughts how wishes can be delivered. It may also focus the population on the poverty of social provision which can only be a good thing. I am amazed here in Canada, where I now work how open people are about such issues and willing to discuss DNR and Living wills etc compared with the UK. Perhaps focusing on this would help some of the social issues caused by memory failure etc later in life. Punters in the UK seemed very reluctant to talk on these matters and probably we as Drs therefore avoided it.

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  • Delighted to hear Dr Brunet thinks being paid for working is unethical; we could do with some free help in the practice, when can you start?

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  • .actually it is grossly unethical to think gps need payment to manage dementia.
    it is grossly unethical to case find/screen for dementia when there is no evidence this is of benefit.
    as usual nhse talks unadulterated nonsense.

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