At the divisions conference in Hobart last week there was much talk of the National Primary Care Collaboratives program and how schemes like this might be the “way of the future” for general practice and for divisions in particular.
The idea seems to follow the example of the UK, which has blazed a trail in getting GPs involved in pay for performance schemes, or “quality and outcomes frameworks” as the management jargon will have it.
The first collaborative projects here have focused on some easily measurable targets for best practice, namely HbA1c levels and the use of aspirin and statins in patients with CHD. The early results show that the GPs involved in these schemes have done well - getting close to their targets of 50% of diabetes patients with HbA1c levels below 7% and 70% of CHD patients using aspirin and statins.
Might we go further down this track and start linking GP remuneration with reaching clinical targets – the way we already do with incentive payments for immunisations, for example?
Before we do, perhaps we should heed the note of caution from those in the UK who are already well down this path. In the BMJtoday a group of British GPs who are already working with pay for performance programs say that while the schemes have some benefits, they are shifting the focus away from what individual patients need and also missing the patients who most need such interventions.
They claim that clinical judgement is stifled by an overemphasis on computer-based management systems using recalls and prompts.
“Interventions become routine and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation,” the doctors say.
Pay for performance programs diminish the responsibility of the doctor to think and encourage a focus on points scored, threshold met and income generated, they say. And programs that target specific risk factors will penalise doctors working in poor areas where overall health is worse and targets are harder to achieve, they claim.
Their message is to beware of schemes that focus on the process rather than outcomes, and which disrupt the dialogue between the doctor and patient.
