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At the heart of general practice since 1960

The conflicts of incentives

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The headlines were all about how GPs were being paid not to refer patients to secondary care. They suggested that the consultation between patients and GPs was being tainted by money. The inference and direct conclusion was that GPs no longer had the interests of patients at the heart of what they did when it came to referrals.

GPs have been incentivised for the way that they carry out clinical activity for years

Really there is nothing new here. GPs have been incentivised for the way that they carry out clinical activity for years. The QOF is the most obvious example of how incentive schemes can disrupt consultations - ‘You’re feeling tired? Do you mind if I ask you about your asthma?’

Payment by results mean that GPs set up systems, reminders and intrusions into routine clinical care in order to meet targets, using a one-size-fits-all public health approach crammed into an intimately personal 10 minute appointment. But the QOF is not the only example of incentivisation. Many LES do something similar, as do schemes designed by CCGs to ’get something back’ for direct funding. More recently there has been the launch of Quality Premium (QP) on antibiotic prescribing. Quite simply we are all going to have to prescribe fewer antibiotics. Only the most romantic idealist would assert that this will have no influence on the interaction between GPs and patients.

I imagine a little QP devil on one shoulder whispering in one ear, ’Do you really need to prescribe antibiotics, those crepitations might not be due to bacterial pneumonia,’ while on the other shoulder the little GMC angel whispers, ’Make the care of your patient your first concern, don’t forget the NICE guidelines on pneumonia suggest treating those at high risk, like this patient.’

And so to referrals. We all have our areas of clinical practice that we struggle with, depending on our experience and the experience of any colleagues we have around us. Importantly GPs tend to be acutely aware of the things that they don’t know and are aware of the symptoms and signs that mean they need help from the big white building. An increasingly litigious atmosphere in the NHS married to an increasingly consumerist approach to healthcare by some parts of the population means that there is less tolerance for uncertainty and perhaps more unnecessary referrals.

Cutting down on unnecessary referrals would save money and time for patients and the NHS. Pragmatically speaking the only mechanism that seems to alter activity is to provide incentives. Despite the inevitable interpretation that our autonomy and integrity is being broken for dirty money, GPs will still strive to do the right things, listening to all the competing, conflicting voices.

Dr Samir Dawlatly is a GP in Birmingham

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Readers' comments (4)

  • Agreed.

    There is no ethical difference between an incentive to act and an incentive not to act.

    The only ethically relevant consideration is "is it incentivising me to do good or to do harm?", and we must ask that question whether we are talking about QOF, referral reduction programmes or any other incentive.

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  • Time to jump ship folks - damned either way.

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  • Ask yourselves this question "Do we work for our patients or the NHS "?
    When ( as we all do ) we hurry a consultation along and not give that particular patient the time they need ( and which if we were true professionals and the patient was paying us as we do our carpenters and plumbers etc ) we are working for the NHS and not our patient
    The only ethical thing to do is resign from the NHS and regain our pride and the honour of being Doctors
    We have lost our balls and honour
    We deserve all the S*** that is being thrown our way
    A line of poetry comes to mind
    "I could not love you half as much loved I not honour more "
    Until we regain our honour and in so doing expose the lies of the NHS we deserve all we get
    And more much more is to come my brothers

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  • I am deplore the way medical profession and specially GPs are treated by all and sundries but and it is big but some times we need to look at some things diff entry like antibiotics prescription. Over use of antibiotics is a perineal problem. I remember attending nations meeting in Manchester Midland in 1992. With question answer time, one GP said if he did not prescribe then the patient will leave the practice???
    Although I am very carefull prescribing AB it happened to my practice :- when told no antibiotics without MSU, patient went to neon outing practice got AB stat and rang our practice to stuff MSU. There you have it folk
    Cost or no cost Antibiotics or analgesics are not not smarties. Indescriminationg prescribing of analgesics we are creating Michael Jackson of our own prescription addicted patients and no point denying that some practices do that...

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