Thursday, 23 October 2008

Sick PCTs incentivising patient death

The ferret has just found of one PCT that is sinking to new unethical depths in the incentivisation of medicine, it certainly would not surprise me if more than one PCT was indulging in this depraved behaviour. The national media has already noticed the unethical incentives offered by numerous PCTs in trying to get GPs to refer less to hospitals, clinical need is being thrown out of the window as the bean counters take over the NHS. In a new PBC scheme in one PCT the following are allegedly 'indicators of access to personalised and effective care', and GPs are being paid to reduce emergency beds, emergency admissions, out-patient referrals and alcohol related admissions, while they are being paid to let more patients die at home. These are the PCT's 'vital signs' that it intends to pay GPs for fiddling, amazingly the fools at Torbay have left the full document on their website, it may not be there for too much longer:

-Emergency bed days per 1000 patients
-Admissions for ambulatory case sensitive conditions per 1,000 patients
-Proportion of all deaths that occur at home
-GP referrals per 1,000 patients
-Rates of admission for alcohol related harm per 1,000 patients

(note- ACS conditions include life threatening problems such as angina, COPD, gangrene, perforated or bleeding ulcer, asthma and many more killers)

I find it hard to comment on this scheme without swearing but I shall nonetheless try. PCTs have already unethically started schemes up and down the country that reward GPs for reducing referrals, irrelevant of clinical need. The Mail calls the PCTs 'sick' and I am inclined to agree with them on this. The new incentivised vital signs detailed above reward GPs financially for reducing referrals irrelevant of clinical need, for reducing hospital admissions for life threatening conditions and for ensuring that more patients die at home. This is not just unethical, I think the PCTs are encouraging GPs to break the GMC's clear guidance on the duties of a doctor, there could be severe consequences for both the PCTs and the GPs if they accept these sick schemes:

"-You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.

-You must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues."

These PCT schemes are an utter disgrace. They demonstrate that the health service is being run by bean counters who have no understanding of the role and responsibility of being a doctor. Any doctor taking part in these schemes should be ashamed and could well be in grave trouble with the GMC, interestingly I wonder whether anyone with a medical degree has been involved in coming up with these ideas at the DoH or in the SHAs? It does emphasise the way in which doctors can be accountable for taking part in sick schemes like this, while medical managers are seemingly immune from ethics and codes of conduct, they can encourage bad clinical practice and they just don't care for the potential consequences in terms of patient harm.


Anon 2 said...

I particularly like the whole "irrelevant of clinical need" aspect which you have included. Well, when I say "like"...

I think that sensationalist comments like this should really be left to the journo at the Daily HateMail.

Here''s an alternate view for you. There is a large number of patients who should be treated outside of hospital but aren't. This type of scheme is designed to encourage GPs to treat them themselves, or to use the services which are already available in the community. Or, and here is a radical thought, to make sure that patients are aware that there is more to the NHS than hospitals and A&E.

Yes this includes some people who are taken by ambulance to A&E - regardless of clinical need - because that actually happens, as Tom Reynolds blog demonstrates.

And yes this includes patients with COPD and asthma because sometimes, they will attend A&E when "clinically" that isn't actually necessary.

To suggest that a PCT would have a policy which is clinically unsound, which would intentionally put people in life threatening situations shows a fundamental lack of knowledge about how they work.

Garth Marenghi said...

Well, your 'alternative' view is about as convincing as yet another PCT soundbite.

You comments demonstrate a rank lack of understanding of the way in which health care and which GPs work.

These unethical and arguably dangerous new incentives put pressure on clinicians to make decisions against the interests of patients because the PCT is putting money ahead of clinical need, this basic point is something you fail to grasp.

It's very easy for the likes of Tom Reynolds and other 'expert' paramedics to sit and criticise people who have to take the responsibility for these decisions, but frankly a few unneccessary referrals are better than less unneccessary referrals and a few unneccessary deaths.

This policy is unethical and dangerous.

It's amusing that the only people who defend these kind of moronic polcicies are those with only a little knowledge, a little knowledge can be a very dangerous thing, this is demonstrated by the government's cohorts of empowered undertrained worker drones in every public sector.

The kind of logic you use would assume that just because say 80% GPs workload is relatively simple work that could be done by someone else, only only needs 20% of the number of GPs we currently have, if this idiotic logic is followed through a dangerous system results, it is all about having slack in the system, it's about recognising the minority of serious problems that need to be addressed immediately.

It's very easy to do an average job 90% of the time, any old muppet can do this, however minimising the errors to an acceptable level is the key, this requires a thorough training and expertise.

So overall your points are at best misguided, at worst ill informed and plain wrong, by putting pressure on not referring patients both as emergencies and electively to out patient clinics PCTs are inevitably going to increase the number of people who have a rare tumour missed or who miss out on some life saving treatment.

It's about simple statistics and logic, something you're more than a little short of I'm afraid.

the a&e charge nurse said...

Fascinating post, Ferret.
I am reminded of Colin Brewers axiom:
".....suffering increases to meet the means available for its alleviation".

It seems to me that current patient volume/demand has resulted in the NHS reaching some sort of tipping point [despite investment hitting a record £100 billion] epitomised by the long running mantra about 'dumbing down'.

I think we need an honest debate what range of services the NHS is realistically able to deliver, with far more of a guarantee on standards.
This would at least reduce the type of horror story recently picked up by Dr Grumble, amongst others.

My own view is that the range of services should be reduced, so for example I personally feel that some patients would be far more comfortable dying at home rather than being rushed into hospital by ambulance when they are very frail and elderly, or suffer with advanced cancer, say ?
Obviously, such decisions would need to be made on a case by case basis.

As you rightly point out nobody on the shop floor trusts the bean counters [at the PCT or DoH] but if clinicians don't grasp this difficult nettle the NHS may face even further disintegration as it tries to be all things to all people ?

Anonymous said...

Obviously, such decisions would need to be made on a case by case basis.

I suggest, diffidently, that they should be made **by the patient** and where that is impossible, by a relative (I realise that may mean they will be taken to hospital) in consultation with relevant medics.


the a&e charge nurse said...

We have around 444,000 institutional deaths each year, Jayann - current projections estimate that fewer than 1 in 10 of us will die at home [by 2030].

According to these authors "people will die increasingly at older ages, with the percentage of deaths among those aged 85 expected to rise from 32% in 2003 to 44 % in 2030.

Death is often a sordid and at times a futile business in A&E, especially when it's a demented 85 year old rushed in by ambulance after a catastrophic CVA, say.

Doctors are often forced to make decisions that are informed in part by arbitrary notions of quality of life, an entirely subjective and personal construct IMHO - but of course, you right it is the patient who should be placed at the centre of any such decision whenever circumstances permit.

Garth Marenghi said...

One of the best ways to avoid these poor referrals is by having continuity of care, and this is something that the DH is deliberately dismantling by forcing Darzi's polyclinics on us all while undermining good local GP practices.

The money that has gone on stupid top down bureaucratic reform and empowerment of people who cannot to the job of GPs (pharmacists for example) should have gone to improving the decent GP system we had in place.

Doctors should be making these decisions on clinical grounds only, they should not have cash incentives affected them, even if they may only be in the back of their minds as it were.

It costs something like 20 quid for a GP appointment, this is great value for money, especially when compared to 25 quid for one call to NHS direct or 27 quid for a useless pharmacist 'medicine review'.

Less top down tinkering and gimmicks designed by idiots please.

Anonymous said...

a & e charge nurse

Doctors are often forced to make decisions that are informed in part by arbitrary notions of quality of life

yes of course. (I don't though think doctors -- or nurses -- were primarily responsible for my mother's having to wait two hours for an ambulance, to take her to a hospital two minutes' drive away, an ambulance called by the doctor who attended her after she collapsed and who suspected a heart attack; I think the powers that be deemed the 'problem' not worthy of an emergency ambulance. -- I was told in advance how long the ambulance would take.)

I objected as I did because of the context of your contention, that is

I think we need an honest debate what range of services the NHS is realistically able to deliver, with far more of a guarantee on standards.

My own view is that the range of services should be reduced, so for example I personally feel that some patients would be far more comfortable dying at home

surely the elderly are already sufficiently short-changed and ignored? if we do have to restrict NHS treatments, couldn't we consider cutting back on, e.g., cosmetic surgery? or the provision of little fire engines for children to ride on on the way to the operating theatre so they won't be scared? Or, gosh, IVF?

(I am signed in to Google but Blogger won't accept that...)


the a&e charge nurse said...

Even the term elderly has become something of a slippery term - when I first started out it used to mean 65+, then 70, and then 75 - now it's 80 [at least in our Trust].

You'll probably think this is a cop out, but I do think we can only make sensible decisions on a case by case basis.

Hospitals are sometimes referred to as "keeping people alive factories" - obviously many stories can be weaved around such a chilling expression.
But since you've pushed me into a corner about where the axe should fall - I would start with managers/admin & then the worried well.

I agree about cosmetic surgery and IVF.

All of us need to think carefully about how much medicine we would like when get older - but it would be immoral to penalise patients who have never got round to considering/addressing these issues.

I remember a TV documentary which included footage of a geriatrician trying to establish if elderly patients [with none fatal conditions] would wish to have CPR performed on them in the event of an unexpected arrest - the responses were both hilarious and heart breaking in equal measure.

When my Dad died of renal failure a week after a heart attack I was glad the nephrologist who had been looking after him never tried to push him into dialysis before he finally became very sick - he would have hated that, a few extra years of life in a permanent state of thanks.

Garth Marenghi said...

Obviously there are limits to what a national health service can provide, however these limits would be so much less if so much money was not wasted by the likes of the PCTs on stupid schemes like this.

jayann said...

I do think we can only make sensible decisions on a case by case basis

I rather agree. But that doesn't quite fit with deciding what can and can't be provided on the NHS -- IMO.

(I am sorry about your father but glad he was spared extra suffering.)