The standards set by the quality indicators will affect not only GPs' pay but also their defence if the care they provide is called into question, says Dr Gerard Panting
The new GP contract puts a strong emphasis on rewarding quality, but what are the implications for practices that lag behind? Will they become targets for action by PCOs? Will the evidence-based quality and outcomes framework raise the standard below which GPs can be found guilty of negligence, resulting in more claims?
Quality and payment
The most obvious and immediate sanction for practices that fail to deliver will be financial as they will miss out on the payments for achieving quality standards.
The four domains of the contract – clinical, organisational, additional services and patient experience – each cover a number of areas, and each of these areas contains quality indicators which are allocated points. For example, under the clinical domain, quality indicators for coronary heart disease include:
- The practice can produce a register of patients with coronary heart disease (6 points)
- The percentage of patients with newly diagnosed angina (diagnosed after 01/04/03) who are referred for exercise testing and/or specialist assessment (7 points)
- The percentage of patients with coronary heart disease whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once (7 points)
- The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less (19 points).
Some quality indicators, for example having a register of patients, will either be achieved or will not, but the majority have minimum and maximum thresholds which affect the payment made to the practice.
Three types of payment will be made:
- Preparation payments, available only in the first three years
- Aspiration payments, which include additional infrastructure costs excluding premises and IT
- Achievement payments.
Preparation payments are not conditional on achievement and are designed to compensate for the effort required to implement quality frameworks in practices. Aspiration and achievement payments are based on the points system.
Aspiration payments will depend upon an agreement between the practice and the PCO and achievement payments will be determined by the standards attained.
Clinical negligence claims
What would happen if, for example, a patient were to sue after suffering a myocardial infarction where the practice in question had not implemented the quality indicators for CHD, so there was no register of patients with CHD, the patient was not referred for exercise testing or specialist assessment, there was no smoking record or encouragement to stop, no monitoring of blood pressure and no cholesterol measurement?
The essence of any clinical negligence claim is the ability to demonstrate substandard care – that is, care which cannot be supported by a responsible body of medical opinion – resulting in harm.
Whether or not the new contract was in place, the doctors in the case above would find it difficult to defend their position. If the diagnosis of CHD had or should have been made, the failure to refer (unless there were suitable facilities within the practice) and to take other basic steps in management would make it impossible to find supportive expert opinion, so breach of duty of care would have to be admitted.
As with the National Service Frameworks, standards set out in the new contract will be highly influential, and are likely to be interpreted by claimants and their lawyers as the standards patients are entitled to expect of their doctors. Any failure to meet them is likely to require the defendant doctor to justify his or her position as being in accordance with responsible medical opinion.
Any damages awarded to the patient will be dependent upon demonstrating that the patient came to harm as a result of poor care, which will in turn depend upon expert opinion.
But what if the practice were a generally good practice with high aspirations and attainments where the patient simply was not within the threshold percentage required within the contract?
Clinical negligence cases focus on the care given to an individual patient and often ignore everything else. However, there may be an even greater problem for the defence in this case because the doctors in the practice would have to concede that their management did not reflect the standards generally aspired to by the practice.This would put the defence on the back foot, even if it did not destroy it entirely.
Other forms of accountability
Clinical negligence claims are just one of the many forms of accountability to which doctors are subject. The GMC or a PCO may take a doctor to task for failing to provide a high enough standard of care and the impact of either or both finding that a particular practice or doctor is failing may be more profound than any clinical negligence claim.
When PCOs monitor performance, for example through complaints and appraisals, they will become aware of doctors whose practice is below average. Exactly how they respond will probably depend upon the individual circumstances.
One option is to involve the National Clinical Assessment Authority (NCAA) which will independently assess the doctor’s practice.This may result in a recommendation for remedial action and the development of an action plan or, if the deficiencies are too profound, a recommendation that the doctor no longer practices.
PCOs are not required to refer doctors to the NCAA but might, through their own internal machinery, determine that continuing to include the doctor’s name on the list damages the efficiency of the service, and remove him or her from the list.
The GMC’s fitness to practise procedures will be changing early in 2004. The separate procedures for findings of serious professional misconduct, seriously deficient performance and inability to practise on grounds of ill health are to be replaced by just one, which asks whether there is any aspect of the doctor’s conduct, performance or health that warrants action on registration. Doctors who fail to keep pace with the rising standards of practice may well find themselves subject to the GMC’s procedures, and, if found to be failing, removed from the medical register.
It is anticipated that the contract’s quality framework will be reviewed and updated over time. As new evidence emerges about the significance or requirements of certain indicators, so they may change, and new areas and indicators may be introduced. A group of experts will oversee the process and consider the latest evidence and make recommendations.
The contract allows practices to control their own workload by determining what, in addition to the essential services, they provide.Those essential services will include the management of chronic diseases – ten of which are the clinical areas set out in the contract – as well as patients who are ill or who believe themselves to be ill with a condition from which they are expected to recover. PCOs are then obliged to ensure that patients have access to the full range of primary care services.