Education And Debate

For Debate: Can contracts drive clinical care?

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7055.477 (Published 24 August 1996) Cite this as: BMJ 1996;313:477
  1. Anthony Hopkins, directora,
  2. Juliet K Solomon, research associatea
  1. a Research Unit, Royal College of Physicians, London NW1 4LE
  1. Correspondence to: Dr Hopkins.
  • Accepted 3 June 1996

The instrument through which a commissioner purchases health services from a provider is, as in other walks of life, a contract, so considerable importance has been attached by the NHS Executive to the contracting mechanism. A contract should in theory influence the quality of the service provided, but they are in many cases an inappropriate vehicle for driving clinical care. Much clinical activity is related to the management of chronic diseases and the effects of aging. The implicit contract here is based not on process and outcome measures but on mutual trust between doctors and patients that the doctors will provide the best care they can within budgetary constraints.

The research unit of the Royal College of Physicians joined forces last year with the National Association of Health Authorities and Trusts with the intention of producing a model contract for a stroke service. Over 30 health care professionals with wide ranging skills in different aspects of stroke care participated. Guided by a review of published research and by discussions, presentations, and written submissions at the workshop, the group had little difficulty in identifying the principal risk factors for stroke, although they considered it unlikely that commissioners would wish to consider their local preventive health strategies and health of the nation targets solely in relation to stroke. Research evidence shows that death rates and other outcomes are more favourable in stroke units.1 The group therefore also determined that the service specification should require that there be a named clinician responsible for the coordination of the stroke service and that an interdisciplinary team comprising doctors, nurses, physiotherapists, occupational therapists, and speech and language therapists should be available, with the input of other supporting professionals depending on individual need. It was also agreed that the state of outcome measurement was …

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