The duty of a doctor.
The GMC booklet ‘Good Medical Practice’ requires that a doctor “Must make the care of your patient your first concern”. (see link )
Most doctors, I believe do just that, and that is one of the reasons that the medical profession is so trusted.
However, at the margins almost everyone to some extent and some people to a major extent, will be motivated by other things including money. It makes sense to design a system so that there is the minimal risk of a conflict of interest for the doctor. One of the reasons that the NHS GP is both cost effective and well trusted is that there is no incentive to over-treat or over-investigate the patient.
In fee for service systems, such as are present in the majority of countries and is present in private consultations outside the NHS, there is an inbuilt incentive for the person providing the service to suggest further or prolonged treatment. A recent paper analysed the number of scanning investigations requested by US doctors who had a financial interest in a scanner. It found a marked increase in the number of scans requested by such doctors with no commensurate improvement in outcomes for patients.
There are risks for patients and for the NHS if there is any possibility of doctors being influenced in their commissioning decisions by personal financial gain. Despite suggested safeguards such as requiring the declaration of interest, and application of Nolan principles to the behaviour of Clinical Commissioning Groups (CCG) it will be impossible to eradicate this risk. It was claimed that the moneys given to Practices under the GP Fundholding scheme were held separately from money that was the legitimate income for the Practice. In fact this separation was not watertight, and GP fundholders were able to gain financially from fundholding funds.
Even more serious for protecting the interests of patients and maintaining patient trust is the risk of doctors coming under financial pressure to withhold treatment that the patient needs. The current proposal for implementing the Quality Premium is that Practices have 15% of Practice income withheld and they are able to recoup that lost income by meeting certain quality targets set by the CCG. Despite claims that this will be paid on the basis of quality and outcomes, there is no robust method of doing this. Outcome measures such as survival in cancer or heart attack, or successful mobilisation and lack of complication after hip replacement may take years to measure and are potentially subject to multiple confounding factors. The CCG will need some in-year measure to justify returning the lost income to Practices. However, such considerations may become irrelevant, as the Quality Premium will not be paid if the CCG is not staying within its budget. As many PCTs are already subject to financial pressures, and as we know that the NHS is already going to be subject to severe financial constraints in the next ten or twenty years (demographic changes, above inflation rises in drug costs, new medical technology and techniques all exacerbated by the outgoing Labour government’s £20bn savings target) it is likely that many CCGs will be threatening to withhold the Quality Premium, unless Practices reduce referral or treatment.
To a certain extent this is already happening – with GPs in some areas being forced to use Referral-management systems, such that a third party will have access to confidential patient information and be able to refuse the referral. The model described being similar to those used by the American Health Maintenance Organisations
In these organisations quality is not improved, far from it.
“A series of perverse economic incentives were instituted from top to bottom so as to seriously compromise the independent clinical judgments of physicians and other health professionals and often to turn the pocket-book allegiance of the health care servers against the interests of their patients, as with gag rules, bonuses for not referring and the like.
“The HMO and its deepening swamp of commercialism over service, of profiteering over professionalism, of denial or rationing of care where such care is critically needed, of depersonalization of intensely personal kinds of relationships, are all accruing and spreading without sufficient disclosure, accountability and structurally responsibility before the damage to life and health is done.” Ralph Nader
A cynic might suggest that this is in the interests of the Government, as it puts a downward pressure on NHS expenditure. I would hope that no thoughtful and conscientious government would genuinely believe that it is in the interests of the government, the country, the NHS or the patient deliberately to undermine the high quality treatment of patients.
It follows therefore, that it is generally not good practice, and is probably incompatible with the promotion of ethical medical practice to make practising doctors directly responsible for the budgets allocated for patient treatment. The most stark and clear example of why this is unethical is demonstrated by the way prison medical officers were paid in the 19th Century. Prison doctors were given a single allocation of finance which was intended to cover both the doctors own remuneration and the costs of all treatment for the prisoners. It will not come as a surprise that patients were frequently under-treated or completely neglected. The doctor who determines a patient’s healthcare needs should not hold the purse used to buy that care.
Another of the duties of a doctor required by the GMC is to respect patients’ right to confidentiality. The Chief Executive of the GMC recently emphasised the importance of this saying “Patient confidentiality is all.”
However, paragraph 249 of the Health and Social Care Bill establishes a corporate body known as the Information Centre. Paragraph 255 (1) a) and b) then makes it law that doctors will have to reveal “any information” that this Information Centre requests of them. This will introduce a further unacceptable conflict of interests for GPs.
- In the current context, therefore, GPs should not be in charge of CCG budgets. CCGs or PCTs should be required to have a Professional Executive committee (PEC), a statutory obligation to take the advice of the PEC and have a medical director as a full member of the board.
- The Quality Premium should not be introduced. There are better ways of encouraging best practice among medical practitioners. Removing 15% of Practice income will simply produce resentment and allowing practices to earn it back under certain circumstances will encourage ‘gaming’.
- Doctors should not be obliged by law to reveal confidential patient data to the Information Centre.
Note also “….. the health of my patient will be my Number One consideration.” Declaration of Geneva by the World Medical Association.
Ralph Nader quoted from the foreword to “Making a Killing: HMOs and the threat to your health” by Jamie Court and Francis Smith 1999