GPs should be rewarded for patient experience to encourage a person centred NHSBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6422 (Published 27 October 2014) Cite this as: BMJ 2014;349:g6422
- Geva Greenfield, research associate, Department of Primary Care and Public Health, School of Public Health, Imperial College London W6 8RP
Person centred medicine is seen as crucial to high quality healthcare in the NHS and abroad.1 The UK government envisions that patients should be “at the heart of everything we do” and that for patients there should be “no decision about me, without me.”2 The NHS constitution says that NHS users should receive a patient centred approach to their care, respecting their needs, values, and preferences.
A person centred doctor is sympathetic and interested in patients’ worries and expectations, knows the patient and his or her emotional needs, discusses the problem and treatment, is definite about the problem and when or if it will resolve, and is interested in its effect on the patient’s life.3 This kind of doctor starts from the patient’s situation, legitimises the patient’s illness experience, acknowledges the patient’s expertise, and offers realistic hope. He or she also develops an ongoing partnership, provides advocacy for the patient in the healthcare system, and shares power and responsibility with the patient.4
Ten minute slots
The delivery of all of these qualities seems almost impossible given the current primary care workload in the UK. General practitioners face increasing demands to follow many clinical quality guidelines and to attain many clinical outcome measures. They are expected to do much more than they can deliver in 10 minute slots, particularly for patients with multiple conditions. No wonder that the NHS as a whole is still far from being patient centred.5 6
One way to influence GPs’ behaviour toward a person centred approach is through pay for performance schemes. The Quality and Outcomes Framework (QOF) was introduced in the UK in 2004 as part of the new General Medical Services contract. This voluntary process awards points for achievements in clinical care (mainly in managing common long term conditions), practice organisation, and providing additional services (such as child health and maternity services). Substantial improvements have been noted since the introduction of QOF, particularly in the management of risk factors for cardiovascular disease and diabetes.7 8
Patient experience is one of QOF’s domains, rewarding GPs for how well patients view their experience at the practice. Four patient experience measures were introduced in 2004-5, totalling 100 points toward the 1050 possible QOF points. These four measures were retained in 2005-6 and increased to 108 points in 2006-7 and 2007-8 (out of a reduced total of 1000). An additional measure was introduced in 2008-9, increasing the patient experience domain to 146.5 points. However, since then these measures have been gradually removed, so that in the 2014-5 QOF not one of the more than 100 measures relates to patient experience.
A return to rewarding patient experience through the QOF does not necessarily mean spending more money; it might just mean that other measures are removed. Delivering person centred medicine may pay off because it provides a better understanding of the patient’s needs. Person centred medicine has a therapeutic value by itself, which can be translated to clinical outcomes such as fewer diagnostic tests and referrals,9 reduced symptom burden,3 better quality of life, and less anxiety and depression.10 For example, better performance on the QOF measure of patient access has been shown to be associated with lower admission rates for long term conditions such as diabetes.11
Overlooking patient experience and focusing entirely on clinical procedures, such as delivering more screening tests, may not be the solution to some of the key challenges facing the NHS. A person centred approach may tell us if additional tests are really needed and why. Perhaps the patient tries to tell us something we’re missing? Hence rewarding GPs merely for delivering more performance measures might be counterproductive.
Measures of patient experience
Measuring patient experience is more challenging than measuring other QOF measures. How should we reward a GP who has empowered a patient to take ownership of his or her health or made a decision together with the patient? Fortunately, the UK has valid measures for patient experience, such as those provided by the National General Practice Patient Survey.12 This survey measures aspects of patient experience such as access, giving patients enough time, listening to their concerns, and involving them in decisions about their care. Several measures from this survey were used in previous versions of QOF to reward GPs who practice person centred care and could be used again in future.
QOF rewards are a practical reflection of values and priorities. If we want person centred medicine to become the norm in the UK we must reward GPs for it, just as we reward them for other aspects of good quality care. We need to provide GPs with the right conditions to deliver person centred medicine, including longer appointment slots. With the current demands on GPs’ time, patient experience is likely to be given less priority than better rewarded measures of care. Ideally, patient experience measures should take at least a fifth of the total QOF measures. Adding patient experience to the QOF conveys a message of the importance attached to improving patient experience in line with the government’s ethos to put patients at the centre of everything we do.
Cite this as: BMJ 2014;349:g6422
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare that I have no competing interests.
Provenance and peer review: Not commissioned; not externally peer reviewed.