The Care Quality Commission declared today to be the day that every GP practice will learn what they really mean by Intelligent Monitoring. Every GP practice will feature in a published database that scrutinises performance against 38 different indicators, ranging from patients’ perceptions about access to their preferred GP, to how frequently our patients turn up in Accident and Emergency.
There’s so much to say about this document that I’m tempted to start a 38-blog series, going through each indicator and its potential unintended consequences in turn, but I’d probably lose the will to live before I got to double figures.
What concerns me most, though, is the inclusion of diagnosis rates in this allegedly intelligent information. Practices are to be judged on their diagnosis rates for dementia (inevitably), Coronary Heart Disease (CHD) and Chronic Obstructive Pulmonary Disease. Diagnose fewer than the CQC think you should have and your practice may be declared as at ‘risk’, fewer still and the phrase will be ‘elevated risk’. Too many risk scores and the practice will be prioritised for an early inspection, with an almost certain guarantee that the inspectors will have their knives sharpened on arrival.
Until now practices have been criticised if diagnosis rates were low, but that was it. This will now change. The threat of an early and uncomfortable CQC inspection will have real teeth, meaning practices will have to do what they can to raise diagnosis rates, regardless of the consequences for patients or any analysis of the ethics of such a situation.
If the row over cash for diagnoses in dementia has taught us anything, it has demonstrated the strength of feeling, both among doctors and the general public, that there has to be an ethical foundation to the making of a diagnosis. The link between a cash payment and a diagnostic label creates an obvious conflict of interests for the doctor, but the ethical issue is that the doctor should not have any self-interest when making a diagnosis – and fear of a CQC inspection creates an arguably more powerful self-interest than a few extra pounds in the pot.
At the RCGP conference in October I made something of a nuisance of myself at the CQC stand, asking whether or not they were going to judge practices on diagnosis rates. It was none other than the CQC myth-buster Nigel Sparrow who reassured me that this would never happen, but in whose universe is the statement ‘elevated risk’ not a judgment call?
How are practices to respond to this?
Let’s take CHD as an example. What are you to do if your diagnosis rates are deemed too low?: diagnose it better when patients come with symptoms? Are we really saying that any doctor lacks motivation to diagnose angina in a patient with chest pain? Isn’t it the first thing we think about?
If there’s no room to increase diagnoses in patients with symptoms, then that only leaves screening. Continuing with the example, the UK National Screening Committee does not recommended it for CHD – but who listens to them these days? What is the advantage of a diagnosis of CHD without symptoms? Intervention with stents and surgery is tempting, but has no prognostic value and probably does more harm than good.
But if screening happens, how will it be undertaken?
The CQC has no interest in this – so the way to avert the eyes of the CQC is to simply diagnose more, any which way. Screen who you like, how you like – all you need is more read codes on the system and you’ll be deemed to be giving better care. Diagnose it any which way: the intelligent monitoring isn’t clever enough to know how well you diagnose or whether you get it right or not, all it can do is count the numbers.
Of course, it might just be that you care about your patients, that you think it’s important to only diagnose when it really is going to benefit them, that you won’t start screening your patients until there’s an official, approved programme to do so – but how naïve would that be?
Enjoy your inspection.
Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.