Understanding quality – the British experience


Category : Medical Rants

Before anyone in this country gets too excited about P4P, we must learn from the British experience. I have written extensively about the problems and potential problems of P4P. The British seem to agree. GP deal ‘not good for patients’

GPs have been particularly successful in hitting the targets with well over 90% met, on average.

The experts, led by Dr Iona Heath, a GP at London’s Caversham Group Practice, said the targets had diminished “the responsibility of doctors to think”.

Instead, they said, GPs were encouraged to focus on “points scored, thresholds met and income generated” – potentially to the detriment of patients.

This BBC article quotes the BMJ. This editorial is free – Careful what you measure

Given the complexity of health care, what are the chances of coming up with a single overall measure of performance? Slim, I fear, especially after reading the study by Ira Wilson and colleagues (doi: 10.1136/bmj.39364.520278.55). When HIV services in the United States were evaluated with a bundle of eight clinical measures, few of them scored highly across more than a handful of measures. Providing uniformly high quality of care is hard if not impossible, even within a dedicated service; so, people prioritise. This means that performance on one measure may tell you little about performance on others.

Obviously I love these quotes because they echo the thoughts that I have espoused here and elsewhere over the last several years. This quote explains the general concept better than I ever have. Unfortunately, you would need access to BMJ to read the original article. But please at least read this quote:

The whole initiative is based on reductive linear reasoning that views the body as a machine and assumes that a standardised treatment will produce an equally standard unit of beneficial outcome. However, any practising clinician knows that the same treatment applied to two people with the same diagnosis can produce very different outcomes. Complexity theory suggests that the body is more usefully regarded as a complex adaptive system, characterised by rich interactions between multiple components that produce unpredictable outcomes. This analogy makes much more sense of clinical experience. Psychological states and social contexts exert measurable effects on the functioning of the body. Standardised treatments ignore all of this.


Now will the medical associations stand tall and do the hard work of explaining this to the suits? I hope so.

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Comments (5)

I had Thanksgiving dinner with a couple from the UK. We only briefly touched on medical care, but their telling comment was they were concerned about the financial future of the NHS. It is not a far stretch to imaging measurement systems being put in place to control cost and thus limit patient choices and treatments.

Steve Lucas

Medical societies have no power compared to the suits, so it doesn’t matter much what they declare at their meetings.

I don’t know how to slow the p4p train down, physicians are watching from the sidelines on this, desperately trying to get in the game. Coach ain’t listening.

DB, You understand that you are an atavism, correct? You hearken back to the days when physicians were not only educated people, but had a healthy dose of skepticism and did seditious things like questioned the status quo.

Perhaps we should instill this more in physicians. To wit, I have gone through baseline metabolism and endocrine control in med school thus far, and was able to tease out of the information they gave us, a better knowledge of how and why we get fat. But, then the instructors went ahead and taught things that the endocrinology simply doesn’t seem to support. No one in my class seems to be questioning this apparent contradiction, and I am such an outlier that my questioning would be disregarded anyway.

When did physicians stop questioning, or did we ever as a group?

PCB, we do have power as a group to overrule the suits. We just have to get together and do it. Getting together is the hard part. I don’t see that happening soon.


One thing that physician (or better epidemiologists) should do is to educate the “suits” in charge about the difference between cost-saving and cost-effectiveness i.e. the difference between actual bottom line and the cost of quality-adjusted life year.

There is a perception among the policy makers that P4P is bound to save money. Yet, it is hardly a given. Look at some of the popular prevention measures, e.g. lipid control for primary prevention. Sometimes even a doctor would say “oh it is cheaper to take statins than to treat heart attack”, forgetting to multiply the former by the number of people one need to treat for a number years to achieve the former. In fact, any look at the studies would show that cost-savings can only be shown for some subgroups of high risk individuals.

Additionally, the all-cause mortality is still 100%, and a lot of people get sick at the end. Unlike infectious deseases, the preventive measures for chronic deseases are simply postponing the desease. I am not arguing that this is a good thing – all of us would rather die later than sooner, but when one tries to impose policies that would actually force people to do something they might not want to do one should at least have some prove of overwhelming benefit to others. Yet I am yet to see anything that would convincingly demonstrate that P4P as a whole (and not just some subset of it applied to a very small subgroup) would save money. Oh, and factoring in the cost of the bureacracy to track all of it would be nice as well.

[…] Pay for performance zinged: Pay for performance is a freight train headed toward American medicine. The Brits have been trying something similar — with not-unexpected poor results. Over at DB’s Medical Rants, DB nails the core problem with these “quality” initiatives, quoting from a British journal: Understanding quality – the British experience […]

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