I am a GP in Wales. My pay has been dependent upon my performance, the performance of the nursing and management team of my practice, and of my patients since April 2004. If the patients take my advice and the tablets I prescribe, if our call and recall systems run effectively, and we are careful to put all relevant data into the computer system, then the Quality and Outcomes Framework (QOF) will reward me handsomely.
At the beginning of the QOF payment system, our practice team agreed to enter all blood pressure values taken on the sphygmomanometer into the patient computer records using the recommended codes. We did not wish to be vulnerable to charges of fraud or cheating or to compromise our professional values as doctors and nurses. At the end of the first year of the new payment system, our practice ranked 146th above the lowest achieving practice in Wales for blood pressure target achievement in the diabetes clinical domain. The data for 2007–2008 are now available and we are now ranked as the 25th practice from the bottom of the Welsh league. Our achievement seems poor and seems to be getting worse.
Where are the lines between accuracy, probity, game playing, cheating, and fraud when it comes to making a computer entry of a blood pressure reading? As a practice we decided to draw our line at what we thought was the minimum for ethical, professional practice. Where do you draw the line?
Mrs Jones' systolic blood pressure reading is above the target value. If it is 151 mmHg can I enter 150 into her records with a clear conscience since everyone knows that the machines are not that accurate? If 151 can become 150, what about 152, 153 or 154? How many millimetres of mercury matter clinically, how many ethically, and how many financially?
Mr Williams' three readings include one systolic value below the target value and one diastolic value below the target I am aiming for. What is a ‘blood pressure reading’? Surely I can enter the below-target systolic and the below-target diastolic readings as a record of today's blood pressure, as I am not going to change his medication anyway? His risk of a cardiovascular event will not change, but my income could drop when I accurately record the readings from the machine.
Miss Evans is in her late seventies and already takes three antihypertensive medications. The QOF does allow me to except her (or should it be her values?) from the payment targets by entering a code for ‘maximum tolerated treatment’. Does that mean that I can use the code when I feel that it isn't safe to do any more when one of my partners has the philosophy and values that lead him to say: ‘There is always more that you can do for the patient if you try hard enough.’?
I've heard of general practices where readings above the target values are entered into text and only readings below target values are coded for audit and payment purposes, and of practices where the hypertension registers are unexpectedly small and targets achieved well.
The first 3 months of each year are now taken up with clinicians and managers scrutinising the practice QOF data to ensure that target values are maximised for data collection day. Dr Smith works through her disease register thinking about each patient and whether or not there are good reasons why they and their values should be ‘excepted’ from the target payment calculations; Dr Roberts is given a list of all patients not hitting the relevant target and works through that list deciding who can be invited to consult for additional efforts to achieve the target values and who can be validly ‘excepted’; Dr Andrews is given a list of patients not hitting the target values and told, ‘If you can “except” five, we will hit the target.’. Which of these doctors, if any, has crossed the line between probity and fraud? Which, if any, has compromised their professional values by game playing?
Friends and colleagues tell me that we have set our standards too high and that my worries are nit picking, because ‘after all everyone is doing it’. Today, QOF data are being used in research studies and papers are being published. A recent paper includes the phrase: ‘QOF data may be presented in a more favourable light in order to maximise practice income.’1 It is a remarkable fact that the blood pressure target achievement of British GPs exceeds the values that have been reported recently in well designed research studies.2,3 What are other practitioners doing to achieve so well in the complex challenging real world? Are we and our patients truly such poor achievers of the targets?
I am an audit and clinical governance nerd; do these issues really matter? A Trust manager has reflected with me that a doctor who does not accurately record a blood pressure reading in a patient's computer record is in breach of the Data Protection Act. She understood that I was distressed and concerned about how pay-for-performance has influenced the professions. Why isn't game playing called fraud? Will the elephant gun be trained on me for asking these questions, or can we agree that there is an elephant in the room?
Notes
Competing interests
My pay is linked to my performance.
- © British Journal of General Practice, 2009.
