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At the heart of general practice since 1960

Yet another stick to beat us with

Benchmarking lab test use is just the latest step in the drive to performance manage GPs, says Dr Robert Morley

We hear the phrase ‘yet another stick with which to beat GPs' so often, I suspect it's the demand for these sticks that's the biggest contributor to the destruction of the rainforests.

The latest beatings coming our way relate to our use of pathology services. We were told last month GPs will be benchmarked on the laboratory tests they order and ‘20% efficiency savings must be found'.
The underlying message – while couched in terms of ‘reducing variation' and ‘driving up quality' – is as always that GPs are profligate and need ‘sorting out'.
Community pathology services are also to be ‘reconfigured' – put out to tender. We all know this means they will be handed over to the cheapest bidder. Never mind the quality, or the long-term relationships built between GPs and their local hospital pathology departments – relationships that are often crucial for the care of patients with long-term haematological or biochemical conditions.

We've heard it all before. Patients attend A&E because of poor GP access, take up hospital beds because of poor GP care, attend outpatients because of the laziness and incompetence of GPs, and get killed and poisoned by reckless GP prescribing.

As ever, it's cost – not quality – that's the real issue. Of course we must constantly seek to improve the care we provide. But it must be done in the right way – through genuine, clinically driven peer review, supported by proper, formative appraisals and appropriate feedback.

Yes, there is poor practice to be weeded out, and sometimes unacceptable variation. But repeatedly headlines are made and inappropriate policies formulated on the basis of figures quoted out of context.

There are numerous reasons why rates for pathology requests, or indeed any other intervention, vary significantly. Patient demographics and morbidity can differ enormously between two practices situated virtually side by side; small list sizes and low prevalence rates can grotesquely distort figures, as seen in the QOF; and there is much evidence to show that GPs with particular experience or interests
actually investigate more, not less, in their area of expertise.

A changing landscape

Not only is our care being scrutinised and criticised more than ever, but the landscape in which this is being done has changed dramatically. Since the advent of PCTs we have been subject to relentless performance management, with its bewildering array of associated jargon – benchmarking, clinical dashboards, Red Amber Green rating, balanced scorecards and the rest. This continues apace, but now we are simultaneously being squeezed between old rocks and many new hard
places.

We are left trying to square circle after circle thanks to the unfunded dumping of work from secondary care and increasing demand from every conceivable angle – with the Department of Health's ‘go straight to your GP if you've had a cough for three weeks, and never mind if you're only 20, you've never smoked in your life and you've just had a really, really bad cold, it's probably lung cancer' initiative really taking the biscuit.

Then there's the unprecedented financial squeeze on general practice funding, frozen year-on-year while the rest of the NHS continues to get annual uplifts. General practice now gets only 7% of total NHS funding, down from over 9% before our new contract.

And to top this, the NHS reforms. Make no mistake, CCGs will be leaned on by the NHS Commissioning Board to deliver the GP performance-management goods. At a recent NHS Commissioning Board conference on primary care performance management, this expectation was made explicit. Responsible officers – deciding on GP revalidation – will also have a conflicting role as local senior primary care commissioning managers.

So the agenda is crystal clear: GP appraisal, revalidation, professional, contractual and commissioning performance management all conflated and placing GPs in impossible conflict. It's not an edifying prospect.

Dr Robert Morley is secretary of Birmingham LMC and deputy chair of the GPC contracts and regulation subcommittee, writing in a personal capacity

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