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A faulty production line

GPs will be judged on their success at making patients better

Professor Alan Maynard argues patients will soon be filling in questionnaires at every consultation as doctors come under even greater scrutiny.

Professor Alan Maynard argues patients will soon be filling in questionnaires at every consultation as doctors come under even greater scrutiny.

The remarkable thing about all healthcare systems and the ways we train doctors is that there is no systematic measurement of how good doctors are at making their patients better.

It doesn't matter whether the healthcare system is private – as in parts of the US or in France, Germany or the Netherlands, where the richer folk buy private insurance – or whether it is public as in the UK and Scandinavia. Where is the outcome measurement to demonstrate that doctors do good to their patients in terms of improving the physical and psychological quality of life?

The exception to this rule is BUPA. Ten years ago BUPA had problems with the ‘fastest cutter in Kent', Rodney Ledward, whose gynaecological surgery damaged many NHS and BUPA patients. Their admirable response was to begin to measure the physical and psychological functioning of patients before and after treatment. This enabled BUPA to offer patients some consumer protection as well as identifying poor practitioners.

Imagine a world of practice-based commissioning – how will GPs ensure consumers are protected and guarantee they are referring to proficient consultants? Might they need to enhance local opinion with a measurement of whether hospital care makes patients better? Florence Nightingale advocated measurement of outcomes in terms of whether patients were ‘dead, relieved or unrelieved' in 1863. Is it time now for GPs to respond to this advocacy?

Consumer power

With such data PBC managers could demand rebates from tariff payments to hospitals if care was deficient – and pay only 50% of tariff if, for example, cataract surgery failed to improve visual acuity. PCTs could do this now but sadly remain in an inefficient torpor, caring all too little whether patients get better.

But how would we get here? There is a need to experiment with care to determine the cost of administering such measurement and to ensure high response rates. Four NHS acute hospitals in England are now experimenting with Patient Reported Outcome Measurement (PROM).

How can health professionals be incentivised to do this and GPs rewarded for implementing it? An obvious reform of the QOF is to include PROM either as a complement or substitute for the patient satisfaction measurement. Given that GPs are human, or as Aneurin Bevan noted ‘the only way to get a message to a doctor is to write it on a cheque', QOF payments will presumably lead to rapid implementation.

Success in the implementation of PROM would enable practice-based commissioners to pay less when patients do not get better. This in time would lead to income losses and redundancy of consultant colleagues.

Any sadness about such threats would be mitigated by QOF PROM assessments of primary care. Data would reveal whether patients were stabilised or got better in the care of community teams. Such data would inform diagnosis as patients would fill in a PROM questionnaire at every GP visit, the results of which would appear on your PC as the patient enters your office.

Such a nirvana is coming your way as the Department of Health is rumoured to be planning to put voluntary PROM in the 2008/9 NHS Operating Framework. Stand by for fireworks!

Professor Alan Maynard is professor of health economics at the University of York

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