Proponents of markets in healthcare make several false claims, but at the top of the list is the claim that patients should be consumers. Consumers need to be rational. They need to be rational, because then they will make rational choices about their care based on clinical outcomes and about value for money for the NHS. This will drive up quality and drive down costs. But patients are not rational. People are not rational. Irrationality with regards to one’s health can lead to vulnerablity, but it doesn’t matter that people are not rational. In fact, I’m inclined to agree with the philosopher William James who thought that irrationality was what made people interesting and human. Doctors have a professional duty to be rational, but not patients. There are some people who get very upset about people not being rational. They are like the ‘vulnerability deniers’ I wrote about before. They need to get over it or they will remain angry and disappointed for a long time.
Martin (not his real name) has attended several different London hospital A&E departments repeatedly in the last 12 months. He called an emergency ambulance on several occasions and has been admitted for investigations and observation for up to a week at a time. He has had several abdominal ultrasound scans, about half a dozen abdominal CT scans and a chest scan. He has had upper and lower gastrointestinal tract endoscopies, gastric biopsies, and blood tests for conditions most doctors have never heard of. He is not a rational consumer of health care.
He is overwhelmingly anxious and convinced that there is something physically wrong with him. His anxiety is transferred to the admitting surgeons who keep repeating tests because they are anxious they might miss a seriously rare, serious problem. His problems actually stem from his childhood experiences and are worsened by his learning difficulties and his adverse social circumstances. There are a lot of people like Martin. Just ask a GP or an A&E nurse.
We collect regular reports about our patients who frequently attend A&E departments. Overwhelmingly, not surprisingly they are either very sick with conditions like end-stage heart failure, respiratory failure (COPD), asthma, ischaemic heart disease etc. or they are very anxious like Martin. A significant number are alcoholic, several abuse drugs and quite a few are regularly beaten up by their partners. Some have serious mental illnesses and personality disorders. Most have a mixture of the conditions I’ve listed. Very few are what I would call ‘timewasters’, people with colds, minor cuts and bruises and so on. Many, like Martin are overwhelmingly anxious. A&E departments, on the whole are not good at dealing with these patients. These patients are not rational consumers of health care. But there is something wrong with them. Unfortunately, we medical professionals are not very good at finding out what it is, or how serious it is. We do a lot of scoping of bodies but not much scoping of brains.
Last month we had a meeting to discuss the quality of care of our diabetic patients. We have about 400 patients with diabetes. Of these 18 have schizophrenia, about half suffer from depression, several abuse drugs, a couple are homeless, about 30 are illiterate or barely literate and about 20 have learning difficulties. We are paid according to how tightly we control our diabetic patients’ blood sugar, blood pressure and so on. Unfortunately because of a significant minority of patients we are losing a lot of money because their diabetes is not under control.
These are patients, not products in a factory. We are not controlling them. We work with them, we don’t control them. Healthcare depends on teamwork. If they do not want to take insulin or blood pressure tablets, if they do not come for their blood tests or fail to submit their feet or urine for inspection, that is either because they have chosen not to or because they are too disorganised or concerned with other problems to prioritise their diabetes. The biggest problem is that these patients fail to attend their appointments or pick up medication despite us spending over £20 000 a year writing, telephoning and texting patients to remind them about their appointments. And still about 20% of them do not come in for their diabetic check ups. They are at high risk of renal failure, blindness, heart disease and other horrendous diabetic complications. They are not making rational choices about their health care.
In 1974 a GP in the Welsh Valleys, Dr Julian Tudor Hart showed that if you called patients in regularly to monitor their blood pressure rather than waiting for them to come in when they felt unwell, you could reduce the risk of death by the complications of high blood pressure by 50%. This is because high blood pressure does not cause any symptoms. Chances are that the first thing you will feel is the crushing central chest pain of a heart attack or the sudden weakness of a stroke. If you wait until you ‘feel’ your diabetes there will be a high chance that you have damage to your eyes or kidneys. Because of this ‘planned care’ has become the ‘modus operandi’ for general practice. (What patients’ need. Julian Tudor Hart’s planned care law) This means that GPs have to take responsibility for their patients.
Whilst we have responsiblity, we have limited ‘control’ of our patients with diabetes and we have even less control of patients like Martin. They also threaten our financial viability because we are charged for every A&E attendance, hospital admission and scan. This is because of the ‘purchaser-provider split‘ which means that hospitals bill us for our patients and consequently have little incentive not to repeat investigations. It is impossible by counting attendances to tell if my patients are attending A&E frequently because they cannot get to see their GP, or because they are sick and anxious.
We pride ourselves not only on high standards of clinical care, but on our commitment to the most vulnerable patients. These people are usually the hardest to treat and the least profitable to care for. They are not rational consumers of health care.
In theory we could ask patients who threaten the financial viability of our practice to leave. We could remove them from our list. Some GPs do that. It is a dark secret. The Royal College of General Practitioners guidance says,
“Where a patient’s continued registration with the practice might be detrimental to the primary healthcare team as a whole, GPs retain the right to remove a patient from the practice list.”
Fortunately for patients it goes on to say that,
Patients’ should not usually be removed from a list for ‘failure to comply with therapeutic or other health advice’
The increasing use of financial incentives is going to make the problem much worse. I think that increasing use of market incentives in the NHS will pose serious problem for practices like ours who look after vulnerable patients and will put them at risk when others find ways to avoid taking responsibility. This is the Inverse Care Law. It is the main problem with private health insurance schemes.
How then can we stop Martin (and many others) from going to A&E, and how are we going to persuade 30 of our most vulnerable diabetic patients to start coming for their checks and start taking their medications?
Unfortunately because of the NHS cuts locally we have had 25% cuts to mental health psychology services and the hospital specialist drug and alcohol service has been cut by half, so we cannot expect too much help from the services best placed to help us meet their needs. This is what happens when a government takes on face value a superficial report that said they could make £20bn efficiency savings over 4 years and then makes cuts accordingly.
The Health Policy Journalist Andy Cowper suggested some alternatives for NHS reform after a challenge from a GP commissioning lead last week on Health Policy Insight. Perhaps the most controversial was:
… patients will get an emailed, itemised invoice following their treatment, which reads “Your treatment cost £TOTAL SUM HERE, paid for by the NHS out of your taxes”.
I will allow patients with long-term conditions to earn a smartphone such as the iPhone in return for regularly using software to monitor and manage their condition, including email and phone support from their care supervisor. The smartphone would be lost for non-compliance, and would not be replaced if mislaid.
These patients are not rational consumers of health care. I do not think they will respond to rational interventions like this. They need to be looked after.
I hope that my description of the patients who are in need has convinced you that fining them is unlikely to help. They are not rational consumers of health care. Whenever I challenge patients about missing appointments they usually have a plausible excuse that I have no way of validating and I have no desire to compromise a delicate therapeutic relationship with my patients by having to enforce a fine that I know they can barely afford.
Since I do not believe that for the most challenging patients financial incentives are apropriate nor that removing them from a GP list is acceptable, I have some alternative suggestions.
One is to improve continuity of care. Almost every serious study of general practice has shown that quality of care, medical errors, unecessary medical procedures, referrals, and patient satisfaction are all improved by better continuity of care. So we are introducing personal lists. Every patient will be registered with their own doctor. This includes our excellent, long-term, dedicated salaried GPs. Continuity helps doctors and patients to get to know eachother, to develop trust and to teach patients who are very anxious to cope with their anxiety and care for themselves. It helps ensure that each doctor knows who they are responsible for.
The second way is to study the problem in more detail and act on the results. Thanks to some excellent medical students I recently had the pleasure to teach, we are about to design a study to look at some of our most challenging patients and explore their reasons for not attending. We will also look at ways of being more proactive with our care. This could involve bringing patients into the surgery, perhaps with the assistance of other patients or taking ourselves out to the hostels where many of the most complicated ones live. The US surgeon Atul Gawande has described successful examples of treating patients just like ours in his article Hot Spotters. He has inspired me and my students.
I will write again about our results and hope to publish them formally in the future.
A Better NHS 
The NHS quasi-Market can never work. Even ‘real’ markets don’t always work because human beings are not rational consumers maximising utility – a realisation that seems to have finally dawned on economists.
The financial incentives and disincentives described above that are dependent on a factor outside the GPs’ control – namely irrational patient behaviour- are ludicrous.
Altho I am a self-declared non-fan of GPs, I admire what Dr T and his team are trying to do. Personalised continuity of care is probably the correct approach. But how do you roll that approach out over England’s10,000 practices? In London in particular it’s a challenge. I am registered with a named GP but have never seen him or her (don’t even know their gender). Each time, it’s a different GP, locus, transient (common in London). Every practice seems to have its own modus operandi.
Anyway, keep us informed of progress Dr T! And good luck.
Continuity of care and a holistic approach is what I was taught during my nurse training 15yrs ago, some things never change. It was always going to cost more to treat those with mental illnesses in the community, so nothing new there either. Ho hum!
Thank you for this very interesting essay.
Some interesting points well made. It will be interesting to see how the single lists pan out. I’ll bet your female partner(s) are booked at least 4w in advance (!) as we are seen often as the “nice” doctors or have more gynae and psych stuff.
What are your PCT’s thoughts on QOF excluding your difficult diabetic patients?
Thank you. We have enough female docs to cover gynae and enough sensitive men to cover (I’m pretty sure) It’s a process rather than an event, and we’re about half-way there. r/e PCT and QOF we can exclude after 3 DNA, but for the LES/ Stretch (9 parameters at annual review) we cannot. This is where we are losing money.
I agree with what you say about marketization and continuity of care. However a couple of points about your diabetes clinics.
Currently, if you studiously follow the advice handed out by NHS doctors, nurses and dietitians about diabetes, you can look forward to worsening control, worsening of your HbA1c, cholesterol etc. and the steady onset of a plethora of diabetic complications. Your doctor will berate you for your worsening control and you will be left wondering what the point is of attending clinics where the ‘help’ you get leaves you in a worse off position.
Saving money by denying patients test strip prescriptions and using a one-off flawed study as a pretext for discouraging patients from testing their own blood sugars, is yet another way in which GPs are preventing patients from taking ownership and responsibility for their own disease management.
The best thing doctors could do for their diabetic patients is to educate themselves about what actually works in diabetic management and then provide patients with the tools and education to manage their own diabetes effectively.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570767/
Bernstein RK. Dr Bernstein’s diabetes solution: complete guide to achieving normal blood sugars. New York: Little, Brown and Company; 2007
When patients see the major improvements they can achieve in their control and quality of life, they become self-motivated, active participants in their own care.
Also, the QOF point collection scheme is a doctor-centred exercise. Patients are well aware that when they get a letter in March demanding they urgently attend for a blood test, it’s not because the doctor is bothered about the patient’s diabetes management or the patient’s health, but rather because the doctor stands to lose out on his bonus if he doesn’t get the blood test ticked off on a tick-box protocol sheet by April.
If GPs are professionals and diabetes is a chronic disease like many others, why do GPs need to be incentivized to carry out what should be a fairly basic part of their job? Should patient care be focused around what’s good for the GPs bonus pay? You say that financial incentives are not appropriate for patients, why then are they appropriate for GPs? These are questions worth considering when designing your services.
r/e the use of diets in diabetes. The problem is not so much, ‘does a low carb diet improve blood sugar control in diabetes?’ (yes it does), but rather, ‘do patients change their diets/ habits following education or advice? (hardly ever)
Thanks for some really useful comments. Your comments about GPs calling patients in because we need the data, rather than it being in the patients’ interest resonate with all the doctors here. The system of incentives is inadequately flexible to deal with the huge range of patients we have, some of whom are very capable and some, like those I’ve described, much less so. the evidence is -at a population level- that QoF/ financial incentives have improved quality of care. GPs like most people are motivated by financial incentives to do more and do it better. It’s not the only motivation and it has the unintended side effect of making some of us ignore the important stuff that doesn’t carry a financial reward. But there has been a lot of work around patient education that has helped improved diabetic care independent of the box-ticking QoF exercises as you have described.
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