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More to care than counting deaths

Is the result all that matters? Managers at the World Cup might say so and it seems health secretary Andrew Lansley would too.

At the time of writing, his keenly anticipated white paper on health is not yet out, but in last week’s speech to the BMA conference, its detail began to take shape.

Mr Lansley was scathing about the previous Government’s obsession with measuring inputs and process, and made crystal clear every area of NHS policy would focus on delivery of outcomes. We’re not talking intermediate outcomes here either – the Government is not prepared to settle for targets on cholesterol and blood pressure. It has set its sights on the final outcome – does a patient have a heart attack or not? Do they live or do they die?

The new NHS commissioning board will be held to account for its performance on outcomes like these, with Mr Lansley proposing targets for reducing ‘mortality amenable to healthcare’, improving cancer survival and cutting premature deaths from heart and lung disease. The board is likely to judge the performance of GP commissioning groups on the same measures, and the QOF too is set to become much more focused on hard outcomes. If the nGMS contract with its registers and its smoking checks seemed radical back in 2004, the new plan is something else entirely.

Immediately, two questions spring to mind – will this work, and is it fair? It is quite possible the answers to these questions will be different. GPs have shown with the QOF that they are eminently capable of delivering to whichever targets have been set, and where they are able to influence outcomes, they surely will.

But for many end-stage outcomes, the degree of influence a GP can have is severely limited, because of the multitude of other factors at play. As a basis for practice pay, targets set on death rates and cancer survival threaten to be at best arbitrary and at worst grossly unfair.

GP academics have resisted hard outcomes in the QOF for a series of reasons – because they may discriminate against practices in deprived areas, where public health is worse, because primary care has only an indirect influence on them and because even then, its effect is normally not seen for many years. To a large extent, these arguments also hold true for GP commissioning groups.

True, Mr Lansley does plan to help out practice groupings in deprived areas with extra commissioning cash. But GP pay could still be reliant on matters over which they have little control. One grouping could be more generously rewarded than another not because it had performed better, but because its local hospitals or public health programmes were better, or simply because it – or its patients – happened to be luckier that year.

Outcome measures could also leave GPs susceptible to accusations of gaming – each suspected cause on a death certificate could come under question.

Counting deaths sounds simple. Mr Lansley will come to realise it is anything but.