Targeting doctors

‘A look into the vast database of documents on the Department of Health website arouses a mixture of despair and disbelief. Central planning may have failed in the Soviet Union but it is alive and well in Britain today.’ (Onora O’Neill, A Question of Trust: The BBC Reith Lecturers 2002, Cambridge.)

This sense of despair and disbelief is even greater when the commissar for health targets (aka the Primary Care Trust’s ‘patch coordinator’) comes knocking at the door. Last week, staff at my health centre were summoned to a discussion of the current performance of local health services according to a range of indicators promulgated in the Primary Care Investment Plan.

It seems that in Hackney, London, we have scored 58 per cent. ’58 per cent of what?’ I inquired innocently. Well, 58 per cent of a possible maximum score that would be achieved if we had performed ‘significantly above average’ in each of 21 different categories.

The commissar circulated a baffling table of statistics revealing the humbling news that we fell below the national average score of 60 per cent. The good news was that we came out one percentage point higher than Tower Hamlets and three points higher than Newham.

There is no room for complacency. The newly appointed apparatchik, an earnest and personable young woman whose livelihood depends on raising the productivity figures of this particular patch, proceeded to exhort the workers to higher levels of performance.

The problem is that the indicators that have been chosen indicate performance in areas that can be measured rather than in what is important. They require a great bureaucracy to administer them and demand the time-consuming recording of data by doctors and nurses and other staff. While proclaiming the goals of quality and excellence, this approach distorts professional practice and produces perverse incentives. Let’s take a few examples.

Several indicators have been chosen as measures of our contribution to ‘improving health’ in the borough. The most obvious problem here is that the health of the local population, as measured for example by the death rate from heart attacks and strokes, is largely determined by factors beyond our control. (The extent to which it can be influenced by medical interventions, whether in the form of cholesterol-lowering drugs or exhortations to adopt healthy lifestyles, is greatly exaggerated.)

Another indicator is the rate of deaths caused by accidents. The prevention of car crashes, fires and industrial injuries has never been regarded as part of a doctor’s job, and it is difficult to imagine how we might extend our efforts in this direction. Perhaps we will soon be required to take responsibility for deaths from drug-related shootings, another significant contributor to local mortality rates.

It is true that the local uptake of Measles Mumps and Rubella (MMR) immunisation (another performance indicator) will have a significant impact on children’s health. But our figures are much more a result of the national MMR-autism scare (and of the failure of official attempts at reassurance) than they are of the efforts of our doctors, health visitors and nurses to persuade parents of the benefits of immunisation.

Other indicators reveal the influence of New Labour’s social policy preoccupations. Though the government has decided that deterring teenage pregnancy is a top priority, this is essentially a social or moral issue, rather than one of health. Though the health commissars believe that GPs should distribute free condoms to schoolchildren as a means of reducing pregnancy rates I believe that this is neither desirable nor likely to be effective.

New Labour’s prurient interest in the sexual activities of young people is reflected in what is perhaps the most bizarre performance indicator – the number of diagnoses of gonorrhoea. Now, in 20 years in general practice I have never diagnosed a case of gonorrhoea: GPs routinely send patients in whom this diagnosis is suspected to the appropriate hospital clinic where the requisite lab tests can be carried out.

To raise performance in this area the best policy would be to discourage clinic attendance and encourage unprotected sexual activity, thus guaranteeing record-breaking numbers of gonorrhoea diagnoses.

In the set of indicators purporting to measure ‘service provision’, pride of place goes to the ‘percentage of patients able to see a GP within 48 hours’. Our visiting commissar solemnly informed us of a local practice that had achieved a performance of 100 per cent, a phenomenon she had witnessed ‘with her own eyes’. This recalls the heroic achievements of Stakhanov, the Soviet factory worker whose record-breaking efforts featured in propaganda films of the Stalinist era.

No doubt, techniques for achieving targets without improving the quality of output or services, of the sort that became notorious in the Soviet Union (and have already made their appearance in the manipulation of hospital waiting lists under New Labour), will soon spread in general practice. We reassured our commissar that we had every confidence that our neighbouring Dr Stakhanov had met the target by a genuine improvement in the quality of service provision, which we would strive to emulate.

As the 48-hour target has become a major focus of government intervention in general practice it is worth examining it more closely. Legend has it that it originated in a focus group convened by one of the New Labour-ish think tanks before the last election. The group was led by a public relations consultant who was infuriated that he could not get an appointment at his local surgery in the Home Counties at a time that could be conveniently fitted into his timetable of commuting to London. His exasperation found a ready response around the table and the 48-hour target was born.

A focus group is unlikely to prove a useful source of insights or policy initiatives in general practice. By its nature such a group excludes babies, children, the frail and infirm elderly, people with severe mental illness or learning difficulties, and many with chronic disease or disability; it is also unlikely to include the homeless, the long-term unemployed, drug addicts and alcoholics, those who do not speak English, recently arrived immigrants, refugees, asylum seekers. In other words, it excludes most of our patients.

On the other hand, a focus group is likely to contain young or middle-aged adults, especially middle-class men. Though this section of the population has traditionally had little need for doctors, in recent years it has been afflicted by a mood of insecurity and introspection that has increasingly taken the form of a morbid preoccupation with health (the vogue for men’s health magazines is one expression of this trend).

Afflicted by self-obsession and ‘disease awareness’, such men now often appear (together with their ‘partners’) in doctors’ surgeries, demanding examination of their testicles for lumps and screening tests for prostate cancer and heart disease (despite the fact that all these examinations and investigations have been shown to have no value).

When New Man gets anxious he needs to see a doctor, if not yesterday, then at least by tomorrow. Hence New Labour, a regime dominated by New Men (and their partners), has seized on the 48-hour target and sought to impose it on general practice. The result of this measure will be to reorganise general practice according to the demands of those who need it least, to the inevitable detriment of those in the greatest need of health care.

This is the latest manifestation of the ‘inverse care law’ (propounded by radical GP Julian Tudor Hart more than 30 years ago), which showed how the middle classes consumed a disproportionate share of NHS resources. In truth, it would not greatly matter if New Man had to wait a week or two for an appointment (in fact, it might be beneficial to have such a ‘chilling out’ period).

What matters more than 48-hour appointments to many of our chronically sick patients is seeing the same doctor or nurse when they come to the surgery. Yet in many surgeries continuity of care is being sacrificed to meet the 48-hour access targets: unfortunately for our patients this cannot be readily turned into a performance indicator.

A remarkable feature of the command mentality now afflicting the health service is the widespread acceptance – by doctors and nurses, as well as by primary care and hospital trusts – of performance indicators that have a distorting or destructive effect on medical practice.

In her recent Reith Lectures (quoted above), Cambridge philosopher Onora O’Neill warned of the dangers of the current direction of policy throughout public services: ‘The pursuit of ever more perfect accountability provides citizens and consumers with more information, more comparisons, more complaints systems; but it also builds a culture of suspicion, low morale, and may ultimately lead to professional cynicism, and then we would have grounds for public mistrust.’

In mid-September 2002, a consultant renal physician, whose hospital in Sheffield was awarded the coveted top ranking of three stars in the NHS league table, wrote to the British Medical Journal giving examples of the problems of resources and waiting lists afflicting his unit (1). He commented that ‘I shudder to think what it must be like in hospitals with two stars or one star or even none’. His judgement is bleak but inescapable:

‘The NHS as it is currently structured, financed and managed, with its politically oriented objectives, has failed the public who use it and the health professionals who work in it’.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

(1) Colin R Brown, ‘NHS league tables are more spin than substance’, BMJ, 14 September 2002