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H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Wednesday, October 15, 2008

Sometimes We See Some Real Academic Nonsense Published!

The following appeared in Australian Doctor this week.

Performance-pay side effects cause concern


By Paul Smith


PAYING GPs to hit performance targets undermines professional autonomy and job satisfaction, according to leading international academics.

State governments and leading Australian health reformers are pushing for a pay-for-performance approach in a bid to drive up primary care quality and improve patient outcomes.

Drawing on the results of the introduction of the policy in the UK’s National Health Service, where 25% of GP income is tied to meeting performance targets, researchers from Kings College, London, said it had led to substantial improvements in intermediate clinical outcomes. They included blood pressure, cholesterol and glycosylated haemoglobin controls as well as the proportion of heart attack and stroke patients treated with aspirin.

Health inequality gaps between the least and most deprived neighbourhoods had also narrowed.

Writing in the Medical Journal of Australia (21 July), Dr Mark Ashworth and Professor Roger Jones, of the university’s department of general practice and primary care, said that “taken together these achievements should translate into substantial national public health gains”.

But they warned that the UK Government had used pay-for-performance — dubbed P4P — as a “big bang solution” and the system was failing to capture the elements of general practice in which many GPs found the greatest professional satisfaction.

More here (needs registration)


The full editorial is to be found here (free registration required):


Most interesting I find is that while ‘pay for performance’ is clearly working to make a difference there is concern that it might destroy professional autonomy.

Let us be quite clear here. The framework seeks to encourage important evidence based clinical behaviour and imposes some measures which encourage clinicians to conduct their practices in a way that suits patient needs. Patients are thus getting better and more patient focussed care – which seems to me to be a very good thing.

The complaints centre around apparently restricting professional autonomy and not measuring things in the patient interaction. The following quote, from the article, seems to reflect the view:

“More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy. Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators.”

There are two points I would make. First, it is possible to measure most of what is mentioned in the quote – so it simply needs some clinician push to make the changes – not just complaining from the side.

The second point is that if professional autonomy means the freedom to ignore evidence of correct practice because you don’t like it that is not autonomy but stupidity!

The GP systems in the UK make conformance with the guidelines easy to capture and record as I understand it and there is no real reason not to follow evidence other that in situations where patient complexity demands adjustments (not all that common).

I really wonder what these academics are trying to say other than we want to right to ignore evidence and couldn’t be bothered trying to improve an already proven to be useful system?

Very odd.


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