Quality - at what cost?


We have heard much about the Health Act and how it will lead to increased competition within the NHS (and therefore increased cost) and also open up the NHS to private providers in a big way, meaning the lawyers and accountants will have a field day making money from negotiating market-driven NHS contracts.
Something very sinister remains at the centre of the Act. Something that could seriously undermine, or even destroy, the doctor patient relationship. It is called the ‘quality premium'.
This concept is all around paying clinical commissioning groups (CCGs) a ‘bonus' if they find themselves with a surplus on their budget at year end and they have met certain ‘targets'. In fact here is the exact DH quote on what the quality premium will be for:
We will ensure that commissioning groups receive a quality premium only where they can demonstrate good performance in terms of quality of patient care and reduced inequalities in healthcare outcomes.'
Now that sounds OK if you read it in isolation. A little like Quality Outcome Framework Payments (QOF) in primary care maybe – good quality care leading to better patient outcomes and hence increased resources. But remember this payment is in the context of commissioning.
Commissioning is all about remaining within budget and having the right contract for the right provider at the best possible price to the NHS. So the quality premium will be paid out to CCGs if they perform well. This means if they come in budget.
Let's be blunt about it - everything in the NHS at the moment is focussed on being ‘in budget'. We see the most draconian of cuts before us with the NHS being asked to slash £20bn from its budget over the next few years. This is unprecedented and has never been successfully done in any other leading health economy before. We are talking about cutting one fifth of the NHS budget – an enormous sum of money. 
So let us take this quality premium down to the consulting room and what might happen there. All GPs now know that money is tight in the NHS. Patients know this too but they still trust their doctor implicitly to do the best thing for them and make the right decision for them. Doctors remain year on year the most trusted profession in the country – with politicians and journalists the least trusted profession in the UK!
But if we have this quality premium in place then the way patients see us will change. We may well decide for good clinical reasons that a course of treatment or a procedure is not appropriate for our patient sat in front of us. However, there will be a niggling thought in the back of the mind of our patient of: ‘Is my GP saying this for good reasons, or because he wants to ensure there is some money left at the end of the year to distribute amongst himself and his pals?'
This is a serious concern and could have far reaching implications for the very trusting relationship we have with our patients and on which the whole basis of our consultation is built upon. We would see ourselves knocked off the top slot in the ranks of ‘trusted professions' - much like in the USA where doctors are less trusted because they have a financial incentive to investigate and treat patients.
We cannot allow this to happen in our NHS and to our doctors. This quality premium must not be allowed to come about in this way. it is vital for our patients and vital for our profession that we fight this dreadful concept.

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