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Wholly unbalanced scorecards

PCTs across the UK are rolling out traffic-light ratings, and some have even begun imposing sanctions on practices that perform poorly under their crude criteria. Whatever happened to the promise of light-touch monitoring?

Looking back, the agreement struck by GPs over the new GMS contract seems to belong to another age. The key principles it enshrined – no new work without pay, incentives based on firm evidence and light-touch monitoring – read like the wishlist of some utopian sect. GPs were probably a little sceptical that those principles would hold even back in 2003, when they voted for the contract by an overwhelming majority. But since then, the extent to which they have been flouted is likely to have turned all but the most dreamily idealistic of GPs into hard-bitten cynics.

In particular, the key principle of light-touch monitoring, under which GPs are treated as trusted professionals, rather than work-shy layabouts, is now being undermined on multiple fronts.

Pulse's investigation this week finds the Government's notorious balanced scorecard scheme, which has been causing controversy ever since it was dreamed up in NHS Tower Hamlets three years ago, has finally come of age. Some 40% of PCTs have now introduced scorecards and another 40% plan to do so by the end of the current financial year. Balanced scorecards, for those who have them confused with the myriad other schemes for assessing the performance of GPs, give practices traffic-light ratings across a wide range of clinical and organisational indicators. One thing they are not is light-touch.

At least five PCTs have already used the balanced scorecard scheme to take sanctions against practices, right up to suspensions and threats of closure, for a variety of offences including in one case refusal to offer extended hours. But then, according to balanced scorecards, there is no shortage of offences to merit sanction. An earlier Pulse analysis found as many as 70% of practices were being handed a red rating – an outright fail – on at least one element of their scorecard. That despite numerous other measures of practice quality, including the QOF and the patient survey, suggesting only a tiny fraction of GPs are significantly underperforming.

The worry now is that as financial pressures on PCTs increase, they will be tempted to take advantage of scorecards to place ever more unreasonable demands on practices. And there are even more fundamental concerns. Balanced scorecards have never been properly validated. Their rollout began before any national scoring system had been released, meaning what GPs are rated on at one trust often differs enormously from in another. And when a national version was finally published, it was produced not by leading academics or the RCGP, but by the management consultancy McKinsey. If GPs' livelihoods are going to rest on whether they are rated green, amber or red, they need at the very least to have trust in the scoring system and faith in the motives behind its use. At the moment, they can have neither.

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