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The conflicts of incentives



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