Generally, as I have commented on in my “Submission to the Dilnot Commission” dated 6 February 2011, I am strongly in favour of a radical change in NHS care of the elderly. I am less sure about the changeover from PCT’s to GP Commissioning. In principle, it seems sensible to put clinicians in control, particularly if they are closer to the customer which GP’s are. However, the changeover is very rapid and GP’s are not best known for their management skills, nor are they immune to the influences of drug companies and the private health care sector.
Controlling the multi-billion pound budget will be a massive challenge for GP’s but the Government has a crude answer to this. The Health Minister, Paul Burstow, is considering incentivising GP’s to “spend NHS funds effectively” by linking their salary to a “quality premium”.
I have never been keen on bonus pay, I believe people should be paid the right rate for the job and then motivated to deliver good quality. Even the best targeted bonus systems can lead to people becoming overly competitive and inclined to take short-cuts to secure higher pay. Often at the expense of teamwork and resulting in distorted outcomes.
The key questions are who defines “spending effectively” – this could be just code for keeping within budget; and what is meant by a “quality premium” – this should surely be about outcomes, but that might lead to GP’s being selective about the patients they take on their list. In both cases GP’s might be inclined to avoid elderly people who will certainly have higher drug costs and more frequent and longer hospital admissions.
There is already concern from the British Medical Association that this system might mean GP’s deny treatments in order to maximise their salaries. This is a justifiable fear since past experience shows that NHS managers had to do this all the time.
Carrot and stick pay structures like this have no surgical precision and potentiallycould lead to very unhealthy outcomes.