Prescribing Incentives Are Grubby Ast Week It Emerged That Finances and Nimbly Calculates That, with Oxfordshire Clinical Enough of a Push, Money Can Be Saved
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comment‘ Professionalism means doing the right ‘thing, not the cheapest or easiest thing NO HOLDS BARRED Margaret McCartney PPA COLUMNIST OF THE YEAR Prescribing incentives are grubby ast week it emerged that finances and nimbly calculates that, with Oxfordshire Clinical enough of a push, money can be saved. Commissioning Group has Scotland, having thrown off the noose suggested that GPs should of the Quality and Outcomes Framework, review patients in nursing still makes regular nods to prescribing Lhomes and “rationalise” prescribing. If incentives. We’re still given payments for enough drugs are stopped or switched medication switches and for decreasing to meet the threshold, the GPs keep half percentages of one drug compared with the cash saved. Cue righteous outrage another. This is a process of diminishing from the national press. It feels grubby returns. So we have a handful of people because it is. with difficult medical histories who There’s little doubt that incentive programmes, are given, say, lignocaine patches and have tried particularly the Quality and Outcomes Framework managing without but would reasonably prefer these in general practice, have led to reflex prescribing to gabapentin. and overprescribing. Doctors must satisfy their General practice is often practised at the edge of paymasters’ suspicions in justifying why they haven’t evidence, with constant compromise, persistent prescribed, rather than why they have. Yet evidence uncertainty, and fluctuating choices and priorities. shows that single disease guidelines for prescribing in Stopping one or two of those prescriptions means multimorbidity aren’t fit for purpose. hitting a target, meaning payouts for practices—but Financial incentives are rotten to the core. Money what about the impact on patients? The conflict of is used to make GPs prescribe, and then to make interest is obvious and unnecessary: we don’t want us not prescribe. This is, in essence, manipulation overtreatment or undertreatment. of the trusted relationships between doctors and It would be possible to pay staff to do medication patients by unseen puppeteers, who suppose that the reviews for people at high risk of overtreatment, while desired outcomes will occur if just the right amount of making flat payments. Better would be to assume that pressure is correctly applied. this should be done anyway. Self employed contractors, many wobbling For every payment by specific incentives, resources financially, are in a bind. Not doing the work means will be concentrated in one area, leaving less loss of income. But doing the work is anti-professional. elsewhere. Why can’t we put the money in centrally No one should support wasting money on poorly and aim for basic, good quality care for everyone, evidenced products. And overtreatment is a harmful using professionalism and transparent data—rather waste of resources. Professionalism means doing the than financial targets—to help us? right thing, not the cheapest or easiest thing. Margaret McCartney is a general practitioner, Glasgow The proposed Oxford scheme is just a continuation [email protected] of the regressive path of general practice in England. Follow Margaret on Twitter, @mgtmccartney Someone sees a chink of light in the black hole of Cite this as: BMJ 2017;357:j2695 the bmj | 10 June 2017 433 PERSONAL VIEW Colin Drummond Cuts to addiction services are a false economy “Savings” in specialist services are increasing pressure elsewhere in the NHS hocking images of training posts in England; and drug users sprawled there can be no further cuts to unconscious or local authorities’ budgets for these standing statue-like services. in an intoxicated state Before 2012, drug and alcohol Shave begun to surface in the media services in England were jointly recently. commissioned by the NHS and local People 50%. In Birmingham, for example, Meanwhile deaths involving heroin authorities. Substantial government with drug the addiction treatment budget was or morphine have more than doubled investment meant a long track record or alcohol cut from £26m to £19m in 2015-16. since addiction services were of success since the 2000s. The dependence The main opportunity to make cuts transferred from NHS control to local Health and Social Care Act made local are is in the workforce, meaning fewer authorities in 2012, and are now at authorities solely responsible for stigmatised specialist addictions psychiatrists, the highest level on record. Last year commissioning these services—and clinical psychologists, and nurses, there were more than 15 000 drug unlike the NHS, council spending on and so their and a greater reliance on doctors related, and over one million alcohol drug and alcohol services is no longer services are without specialist training and related, hospital admissions. The ring fenced. With reduced central often the volunteers with limited training. need for better access to addiction government funding, councils have first to be The number of training posts in services is clear. been forced to cut services to make axed addictions psychiatry has decreased The Royal College of Psychiatrists savings. by 60% since 2006. While 10 years has three solutions: Sustainability People with drug or alcohol ago there were 52 trainees, a Royal and Transformation Plans must dependence are stigmatised and so College of Psychiatrists survey found ensure a return to joint addiction their services are often the first to be that in 2016 just 21 senior trainee service commissioning between the axed. Typically, addiction services in posts were filled. Addictions services NHS and local authorities; there must England have seen cuts of 30% but increasingly struggle to find qualified be at least 60 addictions psychiatrist some areas are planning cuts of up to specialists, leading to lower standards ACUTE PERSPECTIVE David Oliver Unproductive activity and NHS consultants With constrained public money, a slowly rising volume of clinical community services aren’t resourced growing focus arises on doctors’ activity. Appleby emphasised the or functioning. key role in reducing variation importance of considering “quality Into this analysis, I’d add a few in processes and outcomes and adjusted” productivity and the need more ingredients. Firstly, the era of improving value in healthcare, to differentiate elective, outpatient senior doctors doing ward rounds especially how money is spent care from acute, unselected care. He only twice a week, or being on call and what it delivers in outcomes We’re expected noted that, as care becomes more only from home, has gone. We’re that matter to patients and system to see patients complex, a crude calculation is expected to see patients more efficiencies. more frequently, unhelpful. frequently, earlier in admission, at Earlier this year John Appleby at weekends, Of course, doctors work in teams weekends, and during evenings. published an analysis in The BMJ and during and organisations, not as lone This skews the productivity calculus. comparing current and historical evenings. This practitioners. We depend inherently It’s surely the right thing, but its productivity of NHS consultants. The on the availability of decent IT impact on crude productivity is more skews the headline figures suggest that today’s and records, timely investigations, marginal. consultants are less productive productivity logistical support, adequately staffed Secondly, as a King’s Fund report than their predecessors in crude calculus multiprofessional teams, capacity on frontline care recently showed, terms of “volume of output versus (in theatres, intensive care, or hospital doctors can spend a lot of unit of input,” with consultant clinics), or the ability to get patients time battling the poor logistics I’ve expansion unmatched by the more flowing through the system when highlighted. And endemic rota gaps 434 10 June 2017 | the bmj addiction services, or they fall out of treatment during transitions between BMJ OPINION Daniel Grant service providers through tendering Humanising healthcare processes every three years. This continual and unnecessary churn Being a doctor should be about being human, and yet it of service providers is inefficient, is one of the most dehumanising jobs of all. ineffective, and costly. We always talk about the doctor-patient relationship— Cutting community based the need to work with, relate to, and help the person in addictions services has transferred front of us. We can empower patients to ensure that they the burden of patients with drug and have the maximum quality of life for as long as possible. alcohol dependence on to already We can, but we don’t. pressurised emergency departments As a junior doctor, I’m frustrated. I work in an and general psychiatry. The 15 074 environment that suffocates my ability to treat hospital admissions in England for individuals. I spend 95% of my time with the computer illicit drug poisoning is an increase instead of the patient. I identify them by their bed JOHN BIRDSALL/ALAMY JOHN of 6% on the previous year—and number or by their illness, I check their results remotely, which impact on the effectiveness is a staggering 51% higher than in and, at best, I have a brief clinical chat with them and and safety of patient care. To meet the 2005-06. hold their hand. needs of people with drug and alcohol Cuts at a local level make savings— Medicine has moved away from personal problems, we must return the number but what is the real cost? Our care towards depersonalised guidelines of addictions psychiatry training posts previously well functioning treatment in England to 60. system has been downgraded by a There are many reasons for this, but, fundamentally, In addition, NICE approved, short term strategy to save money. medicine has moved away from personal care towards evidence based harm reduction This is a false economy. If we want depersonalised guidelines, academic elitism, and treatments are under attack by the to tackle the rise in drugs related bureaucratic complexities. Most of this isn’t our fault, government.