23 November 2008

Quite Obviously Flawed

If you had asked Dr Grumble whether, if you were to set up a system of performance bonuses (QOF) for GPs they would meet them, he would have guessed that they would. The average GP runs a very tight ship. Practices are heavily computerised. Most patients GPs would need to see for their performance payments would visit their GP quite often. So all the GP would have to do to jump through the hoops and earn extra pay would be get organised and do what the system required. It could be something as absurdly simple as offering advice about smoking and diet or taking a blood pressure. Patients are still smoking and getting fatter and they must know that these things are bad for them - but there is some evidence that a doctor mentioning such issues can help so it may not be quite such a daft way to pay doctors.

How would you negotiate with government over something like this if you were the BMA? Dr Grumble had always thought that the BMA, being dominated by GPs and knowing that GPs would be good at jumping through hoops, would have kept their cards close to their chest in any negotiations with the government. That way GPs would get paid much more than the government had ever intended. But Dr Grumble has now learned that the BMA played with a straight bat. The BMA actually told the government that if you were to give GPs hoops to jump through they would do it. The government did not believe them. They estimated that GPs would only manage to reach 75% (NAO pdf - para 2.11) of their target payments. In fact they got 96.8%. As a result they were paid more than intended. They were paid for doing the job the government imposed upon them. They told the government they would achieve. And they did.

Of course GPs weren't paid for everything you could pay them for. Dr Grumble is not paid for quite a lot of things he does. That is professionalism. But now the Mail claims that GPs 'are ignoring elements of care such as compassion because they do not get extra cash for being nice to patients.' So how would the Mail deal with that unfounded allegation? Another box to tick? What the Mail fails to say, because they are acting in all of this as government rotweilers, is that if anyone is to blame for moving from a professional contract to a jump-through-the-hoops contract it is the government. All this comes, of course, from listening to management consultants who seem to think that people will work only for money and have no concept of professionalism. Professionalism is under threat. It is very sad.

Here in a comment to one of Sam's posts is Dr Grumble's spontaneous tribute to the professionalism of a state school headmaster responsible for educating Dr Grumble's three children. Dr Grumble is not sure he has ever really said thank you to him but he's sure Mrs Grumble has. Sometimes people do not treat professionals well. They think of them as public servants who should be beaten with sticks. The I-blame-the-teachers mentality gets Dr Grumble down. Dr Grumble has noticed when he has visited the schools where his children have been pupils how defensive the teachers can be. He has noticed how inconsiderately long some parents spend with the teacher. He can guess what is going on. These people who have not succeeded in producing successful offspring must be bludgeoning the teacher as if it is the teacher's fault. These imagined encounters always remind Dr Grumble of those relatives who seem to think that you are not going to do the best for their loved one unless they give you the third degree. But Dr Grumble trusts his children's teachers. And he makes a point of thanking them. Sometimes they look surprised.


Anonymous said...

How come you are hospital doctor yet you understand Gp so well Dr G? .. and why don't the blogsphere GPs ask you to stick to your own business? ... It must be because you do do understand GPs 'very' well!


Dr Grumble said...

Many GPs think that hospital doctors have a rather poor understanding of general practice. They are probably right. Most hospital doctors have little interest in general practice.

Some of the blogging GPs do concede that Dr G has some idea of what GP is all about. Actually Grumble's understanding of QOF is weak and based solely on what he has read. So flak may yet be on its way.

The real answer to your query is that Mrs Grumble used to be a GP. She now specialises in a very narrow area and has become quite critical of GPs. But it is very easy to find fault with others when you only work in a very narrow field. The challenge of general practice is to know enough to manage most things and know when you need help. It's that last point that Mrs G finds fault with. She says GPs do not read the guidelines. Dr G then points out that they have guidelines stretching from the floor to the ceiling. Unfortunately hospital doctors remember the few mistakes and do not notice when GPs get it right. GPs have to know about everything. Surely that is the most difficult job of all? Also Mrs Grumble appears to have forgotten that some patients can insist on urgent referral even when it is not indicated and that it is a courtesy to the GP to deal with the patient promptly. There may be some special reason for the 'urgency' that is not apparent in the referral - such as the patient or a posse of relatives constantly hassling the GP.

Dr Andrew Brown said...

As far as I can see you have an excellent grasp of what goes on in general practice and demonstrate a high degree of empathy.

In fact, you seem far too good a doctor to work in a hospital. ;-)

Dr Grumble said...

All these kind comments and tomorrow's post from Dr Grumble refers to an angry blogging Dr Brown. But fortunately it's the other one. You had Dr G worried for a moment, Andrew.