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
- 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 insufficiently advanced to warrant a comparison of the work of individual stroke teams, but the group recommended that providers should collect meaningful process and outcome data about all patients with stroke in a structured way. Purchasers might also want the stroke service to be regularly audited.2
When asked to move on towards considering the content of a model contract, however, the working group was ineffective. A stroke contract cannot specify a volume of cases because a stroke service, spread across community and hospital settings, must care for all patients who have suffered a stroke. It is therefore not feasible to fix a volume of work for contracting purposes, although a rough estimate could be predicted from past experience and sound epidemiological data. Equally, although it might be possible to specify the components of a good rehabilitation service, as the group largely did, it is not appropriate to specify the type or volume of patients going through that service. A stroke may occur in an elderly person living in a nursing home who has already had five strokes and is immobile and demented. Most clinicians would judge it inappropriate to investigate further or to attempt to rehabilitate in any meaningful way such a disabled person. Yet it is difficult to write a contract with exclusions of this type without seeming ageist and biased against those with severe disabilities. Furthermore, process and outcome measures cannot be specified in rehabilitation because the individuality of disability and in particular of handicap is such that therapists quite properly concentrate on patients' specific goals.
Limitations of clinical guidelines
In December 1993 a ministerial task group was set up to review criticisms that clinicians were not involved enough in the contracting process. The task group found that the contracts which they examined varied widely in their complexity but in general focused too much on finance and on measures of activity to engage the interests of clinicians, even when their advice was sought.3 Clinical members of the group reported that there was often little evidence of an epidemiologically based approach to the assessment of health needs, and information on clinical effectiveness and results of clinical audit were often disregarded in these contracts. Also, when clinical involvement was evident, it was mostly at a medical or clinical electorate level and other clinicians were often not consulted.
There has been an enormous proliferation of clinical guidelines and duplication of effort in their production, and the NHS Management Executive has commended certain guidelines to purchasers.4 Indeed, a number of contracts we have seen state something along the lines that “the clinical guidelines developed by the XYZ Society should be followed.” Such a requirement, however, will remain little more than wishful thinking unless a far more robust system of clinical audit than at present is in force. The medical profession at large continues to be suspicious of many outcome measures proposed, largely because the measures fail to take into account the individuality of patients, not only in terms of their severity of illness and comorbidities but also in relation to their values and wishes. Certainly, in some disorders a measure of outcome might reflect care of less good quality—for example, the rate of recurrence of hernias after surgery, subject, as always, to careful analysis of case mix. Indeed, most published examples of outcome measures relate to surgical procedures or acute illnesses such as myocardial infarction. However, much of the practice of physicians relates to the management of chronic disorders and the results of aging. Their care falls into the categories of support, reassurance, and explanation, for which the technical interventions available do not influence outcome very much. If purchasers are serious about using clinical audit to monitor contract performance they need to determine with providers a small number of meaningful measures that are capable of being routinely collected. These must reflect the concerns of users of health services and also be measures by which clinicians would be content, on scientific and practical grounds, to have the quality of their service monitored. Such measures may not necessarily be outcome measures. They may well be measures of process of care, such as the time between onset of symptoms and the provision of thrombolysis. The fact, however, that thrombolysis is cited on so many occasions as an illustrative example, shows the difficulty of finding other measures that truly reflect the quality of patient care.
Importance of trust in provision of non-elective care
We think that there are great difficulties in writing a contract for many professional services. Our service specification for stroke may be one which commissioners and providers find helpful when jointly planning local services. A contract should in theory influence the quality of the service provided,5 but we question the value of a contract in addition to a service specification. We argue that it is unlikely a contract can ever be written for any clinical activity other than the most elective procedures. Using the example of stroke as a model, all that a commissioner can realistically do when planning a non-elective service with his or her local community and hospital trusts will be to say: “Here is £x million—do what you can for patients with stroke within that sum, using the attached service specification document. In particular, we expect to see the appointment of a clinician with particular experience of and interest in stroke care who will be responsible for coordinating the many professions involved in the provision of good care.” The amount of money may improve with time and with better accounting mechanisms, but it can never be more than a broad estimate. With regard to planning a local service, the situation remains similar to that before the health service reforms. A block of money is provided and health professionals are expected to provide the best care they can for patients within the available budgetary limits.
The past 20 years have seen a breakdown in the traditional relationships of trust between various sectors of society. This breakdown is reflected in the demands of users and potential users of health services for greater accountability of the medical profession. Yet one has to consider that the very basis of medical individual practice since the time of Hippocrates is that physicians provide their knowledge and skills to individual patients, with the implicit promise that they will do their best for them. The implicit contract is based on trust. We acknowledge that it would be totally unwise to trust a poorly educated or out of date doctor, and it is right that since the health service reforms, the profession has laid increasing emphasis on evidence based medicine, continuing medical education, and clinical audit. In the final analysis, however, we believe the contract to be a paper tiger that cannot ensure good care. We argue for renewed emphasis on trust and mutual respect.
The research unit of the Royal College of Physicians is supported by generous donations from the Wolfson Foundation, the Welton Foundation, the college's Help Medicine Appeal, and other charitable donations. We thank Dr Charles Wolfe and Dr Derick Wade for their comments on earlier drafts of this paper.