Guest Editorial - (2004) Volume 12, Issue 1
Professor, HarvardMedical School and Harvard PilgrimHealth Care, Boston, USA
To an American, the principles of the new General Medical Services (GMS) contract for general practi-tioners (GPs) in the UK provide a glimpse into a future much espoused but little achieved in our own country. To be sure, American experts have advocated that payment be related to performance. Performance measures much like those proposed in the GMS contract have been operationalised in a set of volun-tary measures used by the National Committee on Quality Assurance, which claims that as many as 55 000 deaths per year could be avoided if such targets were achieved.[1] The use of these performance indi-cators has spawned a multitude of what are called ‘chronic illness management’ models to improve our achievement of process and outcome standards but whose effectiveness has largely been unevaluated. But, despite the abundant rhetoric, we have moved for-ward in only small ways.
And now, as the GMS contract claims, UK general practices will soon be operating under a ‘framework {that} represents the first time any large health system in any country will systematically reward practices on the basis of the quality of care delivered to patients’. For the first time, we can actually see how to apply such a framework, what it accomplishes, and perhaps what additional benefits or unintended consequences such an approach generates.
This bold initiative should help answer several questions. Among these are: will general practices be able to achieve these targets? How will they do it? Will mortality and morbidity improve as these targets are implemented, and by how much? The GMS contract also raises some substantial concerns that could drive right to the heart of the role general practice plays in the architecture of a healthcare system. First, do we need to worry about Rene´ Dubos’ warning that ‘some-times the more measurable drives out the most important’?[2] Second, what are the unintended con-sequences that might occur and would we know them if they happened?
A concern in America is our generally poor per-formance even though health insurance companies have long been pressed to achieve specified perform-ance measures. The quality improvement field has tried, with only modest success, to show that quality improvement methods could improve performance. Some insurance companies have been able to improve performance by employing indirect methods targeted on patients and the medical practices – reminders, checklists, and education, for example. More recently, chronic illness management methods have been ad-vocated, wherein a mix of systems improvements, registries, dedicated manpower (usually nurses), acti-vation of community resources, and patient self-management have been assembled into programmatic initiatives. In the face of mixed results from these efforts, experts have increasingly cited the absence of financial incentives as the reason why such efforts have not been more successful.[3]
With your initiative, we can now examine directly the role that financial incentives play in driving performance achievement. Will these incentives stimulate general practices to achieve these targets, and how will they do it? The GMS contract gives little guidance about the ‘how’. In effect, the UK is creating a vast, pluralistic experiment in clinical practice organisation design. The results should be most informative to others contemplating a general practice-based initiative to achieve these targets.
Another assumption lurks behind this design: that if structure, process, and outcome targets for the ten disease areas are indeed achieved, health will improve. But presumed improvements are based largely on single measure studies that are often summed to claim dramatic outcome results. And yet these initiatives may interact in unpredictable ways. The GMS contract performance framework gives researchers an oppor-tunity to examine the relationship between the port-folio of indicators and the resulting in• uence on morbidity and mortality, as well as hospital, drug, treatment and consultant use. Since the UK NHS has all-inclusive coverage and access to data, you should be able to study this issue. The results should help answer the question of how much improvement in health will be delivered by meeting such targets, and at what direct cost.
On the worrying side, the GMS contract might also do harm. In simple terms, my concern is whether using specific targets, with considerable money riding on them, will generate unintended consequences that might undermine the value of general practice in the UK health system. The pursuit of indicator measure-ments might fragment care and reduce continuity. Combined with the threat to continuity from the change in after-hours coverage, will there be less contact between a patient and their GP? If so, one could speculate that trust might erode over time. There are many who ascribe the success of general practice at managing patient demand in the NHS to the continuity and trust that patients have in their GP. Will this be at risk?
In addition, there are other functions that might degrade as the monetary incentives divert energy to meeting the indicator targets. To name a few: will the practice’s management of ‘soft’ psychosocial issues deteriorate; will access for indeterminate conditions and concerns degrade; will the rigour of the referral decision be affected; and will the ability of the practice to ‘absorb’ demand (as described elegantly by David Haslam[4]) be reduced? These seem to me to be real risks and unintended possible consequences of the GMS contract.
To a supportive observer, the contract and plan pay too little attention to possible unexpected, and even expected outcomes, other than the indicators. With a little work, experts could identify the core functions and competencies that general practices have provided and develop some sentinel measures to track what happens to them.
The world is grateful to the UK for taking the first leap into pay for performance for quality. We watch with interest. And as we wish this bold move well, we also hope that you will watch closely to see both how and if it works and what possible unintended risks might be generated.
